Provider Demographics
NPI:1275590697
Name:ANCONA, RICHARD C (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:ANCONA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2900
Mailing Address - Country:US
Mailing Address - Phone:631-979-6466
Mailing Address - Fax:631-979-6475
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:631-979-6466
Practice Address - Fax:631-979-6475
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135693208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB11227Medicare UPIN
NYRA023A2120Medicare ID - Type Unspecified