Provider Demographics
NPI:1194984914
Name:STICKLES, SCOTT MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:STICKLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6257
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-0257
Mailing Address - Country:US
Mailing Address - Phone:718-204-4995
Mailing Address - Fax:
Practice Address - Street 1:8940 56TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4933
Practice Address - Country:US
Practice Address - Phone:718-335-5532
Practice Address - Fax:718-505-0241
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248461-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03109551Medicaid
NYG400045600Medicare PIN
NY03109551Medicaid