Healthcare Provider Details

I. General information

NPI: 1487675104
Provider Name (Legal Business Name): MARY ANDREA DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9116 101ST AVE
OZONE PARK NY
11416-2219
US

IV. Provider business mailing address

9116 101ST AVE
OZONE PARK NY
11416-2219
US

V. Phone/Fax

Practice location:
  • Phone: 718-482-0010
  • Fax: 718-482-0012
Mailing address:
  • Phone: 718-482-0010
  • Fax: 718-482-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN006076-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN006076-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberN006076-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: