1063457604 NPI number — DR. KINGA MARTA RICCOBONO M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063457604 NPI number — DR. KINGA MARTA RICCOBONO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICCOBONO
Provider First Name:
KINGA
Provider Middle Name:
MARTA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CIELOSZYK
Provider Other First Name:
KINGA
Provider Other Middle Name:
MARTA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063457604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10087-5051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-876-5555
Provider Business Mailing Address Fax Number:
516-876-1236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 FRANKLIN AVE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11530-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-240-8700
Provider Business Practice Location Address Fax Number:
516-240-8787
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  230434 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 230434 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02801201 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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