Provider Demographics
NPI:1063457604
Name:RICCOBONO, KINGA MARTA (MD)
Entity Type:Individual
Prefix:DR
First Name:KINGA
Middle Name:MARTA
Last Name:RICCOBONO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KINGA
Other - Middle Name:MARTA
Other - Last Name:CIELOSZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5051
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5051
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-1236
Practice Address - Street 1:1001 FRANKLIN AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2925
Practice Address - Country:US
Practice Address - Phone:516-240-8700
Practice Address - Fax:516-240-8787
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230434207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02801201Medicaid
NY155446Medicare UPIN