Provider Demographics
NPI:1295809671
Name:CAVALLARO, RICKY SAM (DC)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:SAM
Last Name:CAVALLARO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OSCEOLA PL
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-9500
Mailing Address - Country:US
Mailing Address - Phone:315-487-5200
Mailing Address - Fax:
Practice Address - Street 1:100 OSCEOLA PL
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1229
Practice Address - Country:US
Practice Address - Phone:315-487-5200
Practice Address - Fax:315-487-1110
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU11661Medicare UPIN
NY52539BMedicare ID - Type Unspecified