Provider Demographics
NPI:1720093453
Name:ROBERT C MICKATAVAGE MD PC
Entity Type:Organization
Organization Name:ROBERT C MICKATAVAGE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:203-778-1381
Mailing Address - Street 1:3020 WESTCHESTER AVENUE
Mailing Address - Street 2:# 101
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2562
Mailing Address - Country:US
Mailing Address - Phone:914-967-4400
Mailing Address - Fax:914-967-6416
Practice Address - Street 1:3020 WESTCHESTER AVENUE
Practice Address - Street 2:# 101
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2562
Practice Address - Country:US
Practice Address - Phone:914-967-4400
Practice Address - Fax:914-967-6416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00565513Medicaid
NYWKW581Medicare PIN
NYB11902Medicare UPIN