Provider Demographics
NPI:1376532499
Name:DETRAGLIA, ALICIA (MD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DETRAGLIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 NEWELL ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5313
Mailing Address - Country:US
Mailing Address - Phone:315-798-9300
Mailing Address - Fax:315-793-8320
Practice Address - Street 1:807 NEWELL ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5313
Practice Address - Country:US
Practice Address - Phone:315-798-9300
Practice Address - Fax:315-793-8320
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228220-1207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02428600Medicaid
NY02428600Medicaid
NYH85425Medicare UPIN