Provider Demographics
NPI:1922041524
Name:ISSA, RICARDO FABIAN
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:FABIAN
Last Name:ISSA
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 1:1141 SHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:718-236-8525
Mailing Address - Fax:646-637-9066
Practice Address - Street 1:123 E 61ST ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-593-1211
Practice Address - Fax:646-637-9066
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2052995Medicaid
H10134Medicare UPIN
NY839302Medicare PIN