Provider Demographics
NPI:1134116387
Name:RACANIELLO, ANNETTE F (DO)
Entity Type:Individual
Prefix:DR
First Name:ANNETTE
Middle Name:F
Last Name:RACANIELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-0078
Mailing Address - Country:US
Mailing Address - Phone:631-286-2355
Mailing Address - Fax:631-286-6808
Practice Address - Street 1:1 ANDIRON LN
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-0078
Practice Address - Country:US
Practice Address - Phone:631-286-2355
Practice Address - Fax:631-286-6808
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01153048Medicaid
NYA400026047Medicare PIN
NY01153048Medicaid