MEDICARE: MARISEL PICHARDO

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	174400000X	Specialist	1153098	NY

General Provider Information

NPI Number	:	1295678803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISEL PICHARDO

Provider Business Mailing Address
First Line	:	11225 34TH AVE APT 1G
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-1402
Country	:	US
Telephone Number	:	646-944-2288
Fax Number	:	646-944-2288

Provider Business Practice Location Address
First Line	:	11225 34TH AVE APT 1G
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-1402
Country	:	US
Telephone Number	:	646-944-2288
Fax Number	:	646-944-2288

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

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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Directions to “ MARISEL PICHARDO ” Practice Location

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