Provider Demographics
NPI:1760704845
Name:FATA, RICHARD JOHN
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:FATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 HEARTHSTONE DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5037
Mailing Address - Country:US
Mailing Address - Phone:631-493-3417
Mailing Address - Fax:
Practice Address - Street 1:5507 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2031
Practice Address - Country:US
Practice Address - Phone:631-473-8706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist