Healthcare Provider Details

I. General information

NPI: 1083673677
Provider Name (Legal Business Name): MARCELINA MEDRANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

IV. Provider business mailing address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax: 718-816-3611
Mailing address:
  • Phone: 718-816-6440
  • Fax: 718-816-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number111919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: