Provider Demographics
NPI:1497729099
Name:RICCIARDELLI, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:RICCIARDELLI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-574-8354
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:112 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1329
Practice Address - Country:US
Practice Address - Phone:631-473-3900
Practice Address - Fax:631-474-4475
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2019-11-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1601461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD91832Medicare UPIN
NY07F831Medicare ID - Type Unspecified