Provider Demographics
NPI:1659366862
Name:KRICKELLAS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KRICKELLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:KRICKELLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:321 MARINE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8003
Mailing Address - Country:US
Mailing Address - Phone:718-680-7724
Mailing Address - Fax:718-745-3651
Practice Address - Street 1:321 MARINE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8003
Practice Address - Country:US
Practice Address - Phone:718-680-7724
Practice Address - Fax:718-745-3651
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163775207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63389Medicare UPIN
59D001Medicare ID - Type Unspecified