Provider Demographics
NPI:1154395408
Name:KWICKLIS, MONICA (MD)
Entity type:Individual
Prefix:DR
First Name:MONICA
Middle Name:
Last Name:KWICKLIS
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 1:7785 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367
Mailing Address - Country:US
Mailing Address - Phone:315-376-5287
Mailing Address - Fax:315-376-3228
Practice Address - Street 1:7785 N STATE ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367
Practice Address - Country:US
Practice Address - Phone:315-376-5287
Practice Address - Fax:315-376-3228
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00836562Medicaid
NYB82467Medicare UPIN
NYBB4401Medicare ID - Type Unspecified