Provider Demographics
NPI:1063741023
Name:FORD, KECIA PATREASE (MD)
Entity type:Individual
Prefix:
First Name:KECIA
Middle Name:PATREASE
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PIERSON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-7331
Mailing Address - Country:US
Mailing Address - Phone:917-940-7687
Mailing Address - Fax:
Practice Address - Street 1:30 MERRICK AVE
Practice Address - Street 2:# 105
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1580
Practice Address - Country:US
Practice Address - Phone:516-542-0255
Practice Address - Fax:516-542-0276
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60 247332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY247332-1OtherNY LICENSE