Basic Information
Provider Information | |||||||||
NPI: | 1083613509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICCIO | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 WASHINGTON AVE | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | HAMDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065183267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032483013 | ||||||||
FaxNumber: | 2032482878 | ||||||||
Practice Location | |||||||||
Address1: | 310 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | EAST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065122919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034671800 | ||||||||
FaxNumber: | 2034688343 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 10/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 022540 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110179063 | 01 | CT | RAILROAD MEDICARE | OTHER | 010022540CT01 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER | 022540 | 01 | CT | CONNECTICARE | OTHER | 2047711 | 01 | CT | AETNA | OTHER | NHP075 | 01 | CT | OXFORD | OTHER | 0Q2055 | 01 | CT | HEALTH NET | OTHER |