Provider Demographics
NPI:1740263797
Name:RICONALLA, EMMANUEL B (MD)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:B
Last Name:RICONALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DRIVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:60 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4133
Practice Address - Country:US
Practice Address - Phone:845-343-6216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY217108207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02195366Medicaid
NY07L6201Medicare PIN
H37109Medicare UPIN