Provider Demographics
NPI:1558307256
Name:RICCIARDI, RICCARDO JR (MD)
Entity Type:Individual
Prefix:
First Name:RICCARDO
Middle Name:
Last Name:RICCIARDI
Suffix:JR
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 1:532 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 142
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3672
Mailing Address - Country:US
Mailing Address - Phone:516-931-0041
Mailing Address - Fax:516-822-1686
Practice Address - Street 1:21008 NORTHERN BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3211
Practice Address - Country:US
Practice Address - Phone:718-539-5100
Practice Address - Fax:718-539-2706
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY186804208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01518381Medicaid
NYA400022049Medicare PIN
F27676Medicare UPIN
NYG400000909Medicare PIN
NY0105ESMedicare ID - Type Unspecified