Provider Demographics
NPI:1124881776
Name:MCGILLICUDDY, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:MCGILLICUDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 SOUTH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2418
Practice Address - Country:US
Practice Address - Phone:845-416-5048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine