Provider Demographics
NPI:1821195793
Name:GRAGEDA, RENEE RICAFRENTE (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:RICAFRENTE
Last Name:GRAGEDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-1921
Mailing Address - Fax:718-334-3432
Practice Address - Street 1:9037 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-6032
Practice Address - Country:US
Practice Address - Phone:718-334-6400
Practice Address - Fax:718-334-6430
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154283208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00855734Medicaid
NY00855734Medicaid