Provider Demographics
NPI:1578527941
Name:CITAK, KENNETH A (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:CITAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 EAST RIDGEWOOD AVE
Mailing Address - Street 2:EAST WING 2ND FLOOR
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-444-0868
Mailing Address - Fax:201-493-0797
Practice Address - Street 1:1200 EAST RIDGEWOOD AVE
Practice Address - Street 2:EAST WING 2ND FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-444-0868
Practice Address - Fax:201-493-0797
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA558792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4574206Medicaid
E88359Medicare UPIN
675620Medicare ID - Type Unspecified
NJ4574206Medicaid