Provider Demographics
NPI:1265593719
Name:RENGIFO, RICARDO L (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:L
Last Name:RENGIFO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 PARSONS BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1062
Mailing Address - Country:US
Mailing Address - Phone:718-746-1215
Mailing Address - Fax:718-747-6395
Practice Address - Street 1:333 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1062
Practice Address - Country:US
Practice Address - Phone:718-746-1215
Practice Address - Fax:718-747-6395
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0983222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00167322Medicaid
NYB88601Medicare UPIN