Provider Demographics
NPI:1124274089
Name:PREMDASS, CHERRYL ANN (MD)
Entity type:Individual
Prefix:
First Name:CHERRYL
Middle Name:ANN
Last Name:PREMDASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VALENTINE DR
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-9616
Mailing Address - Country:US
Mailing Address - Phone:860-545-5000
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1771
Practice Address - Fax:321-434-1775
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50454207Q00000X
WI19557-875207Q00000X
CT66149207Q00000X
CTAS2383278-0709208600000X
NY289112208M00000X, 207Q00000X
SC37443208M00000X
FLME124797208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME124797OtherFL MEDICAL LICENSE