Provider Demographics
NPI:1376359752
Name:CHERRY, RICKY
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:CHERRY
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 1:161 E MAIN ST # 1
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2879
Mailing Address - Country:US
Mailing Address - Phone:631-360-7578
Mailing Address - Fax:631-360-7687
Practice Address - Street 1:161 E MAIN ST # 1
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2879
Practice Address - Country:US
Practice Address - Phone:631-360-7578
Practice Address - Fax:631-360-7687
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCRPA-5298207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine