Provider Demographics
NPI:1275691149
Name:ISTRICO, RICHARD A (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:ISTRICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 CROSSBAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414
Mailing Address - Country:US
Mailing Address - Phone:718-738-9115
Mailing Address - Fax:718-738-9127
Practice Address - Street 1:15801 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414
Practice Address - Country:US
Practice Address - Phone:718-738-9115
Practice Address - Fax:718-738-9127
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P391766OtherOXF
9009553OtherCIGNA
1C6680OtherPHS
24A861OtherBC
12264Medicare ID - Type Unspecified
9009553OtherCIGNA