MEDICARE: DR. ANDRES J. DE LEON MEDERO MD

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	207P00000X	Emergency Medicine Physician	312375	NY
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1104227776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDRES J. DE LEON MEDERO MD

Provider Business Mailing Address
First Line	:	PO BOX 1961
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-0961
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	457 ATLANTIC AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-2107
Country	:	US
Telephone Number	:	718-530-1144
Fax Number	:

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

Provider Enumeration Date	:	09/14/2014
Last Update Date	:	01/07/2022

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