Provider Demographics
NPI:1750466108
Name:RACINE, ANDREW D (MD,PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:RACINE
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 EASTCHESTER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2604
Mailing Address - Country:US
Mailing Address - Phone:718-405-8040
Mailing Address - Fax:718-405-8048
Practice Address - Street 1:1621 EASTCHESTER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2604
Practice Address - Country:US
Practice Address - Phone:718-405-8040
Practice Address - Fax:718-405-8048
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166683208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01062353Medicaid
NYE87267Medicare UPIN
NY31F40Medicare ID - Type Unspecified