MEDICARE: ADIEL DERKHIDAM

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	363LP2300X	Primary Care Nurse Practitioner	3763318	NY

General Provider Information

NPI Number	:	1538015235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADIEL DERKHIDAM

Provider Business Mailing Address
First Line	:	24 FLORENCE ST
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11023-1109
Country	:	US
Telephone Number	:
Fax Number	:	516-660-6607

Provider Business Practice Location Address
First Line	:	19002 JAMAICA AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-2034
Country	:	US
Telephone Number	:	718-577-2211
Fax Number	:

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

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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Directions to “ ADIEL DERKHIDAM ” Practice Location

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