Provider Demographics
NPI:1386634939
Name:TICE, HAROLD MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:MITCHELL
Last Name:TICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:110 MARCUS DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4228
Mailing Address - Country:US
Mailing Address - Phone:631-390-1793
Mailing Address - Fax:631-390-1780
Practice Address - Street 1:229 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3295
Practice Address - Country:US
Practice Address - Phone:516-256-1558
Practice Address - Fax:516-256-0758
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-09-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1690782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01468588Medicaid
NY01468588Medicaid
NY04I941Medicare PIN