Provider Demographics
NPI:1497849616
Name:RACANELLI, MARTIN LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LEONARD
Last Name:RACANELLI
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 1:205 EAST MAIN STREET
Mailing Address - Street 2:SUITE 2-6
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-427-1122
Mailing Address - Fax:631-549-6839
Practice Address - Street 1:205 EAST MAIN STREET
Practice Address - Street 2:SUITE 2-6
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-427-1122
Practice Address - Fax:631-549-6839
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00761899Medicaid
NY05A131Medicare ID - Type Unspecified
NY00761899Medicaid
NY05A131Medicare PIN