MEDICARE: DR. ANDREA D. MALLER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TUV006193-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TUV006193-1	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1083780233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREA D. MALLER OD

Provider Business Mailing Address
First Line	:	2748 HYLAN BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4658
Country	:	US
Telephone Number	:	718-979-2200
Fax Number	:	718-979-3435

Provider Business Practice Location Address
First Line	:	2748 HYLAN BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4658
Country	:	US
Telephone Number	:	718-979-2200
Fax Number	:	718-979-3435

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	02/10/2010

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