Provider Demographics
NPI:1003887878
Name:RICCA, RICHARD JAMES (MD, FACS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAMES
Last Name:RICCA
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335A MEETING HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5051
Mailing Address - Country:US
Mailing Address - Phone:631-287-6570
Mailing Address - Fax:631-287-6578
Practice Address - Street 1:335A MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5051
Practice Address - Country:US
Practice Address - Phone:631-287-6570
Practice Address - Fax:631-287-6578
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143299174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00929039Medicaid
NYA62997Medicare UPIN
NY70F001Medicare PIN