Provider Demographics
NPI:1063458834
Name:MARICI, KATHLEEN B (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:B
Last Name:MARICI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-697-3540
Practice Address - Fax:518-697-3551
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02489861Medicaid
NY9X5701Medicare PIN
NY02489861Medicaid