Provider Demographics
NPI:1154400406
Name:RECON-BUCEVIC, MYRA C (MD)
Entity type:Individual
Prefix:DR
First Name:MYRA
Middle Name:C
Last Name:RECON-BUCEVIC
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 1:7925 WINCHESTER BLVD
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2128
Mailing Address - Country:US
Mailing Address - Phone:718-264-3950
Mailing Address - Fax:718-264-3591
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3225
Practice Address - Fax:718-883-6193
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2368922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY0033S231Medicare ID - Type Unspecified
NY00246075Medicaid