Basic Information
| Provider Information | |||||||||
| NPI: | 1376804096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 732 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112321306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122267666 | ||||||||
| FaxNumber: | 2122027988 | ||||||||
| Practice Location | |||||||||
| Address1: | 732 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122267666 | ||||||||
| FaxNumber: | 2122027988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 274910 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.