Provider Demographics
NPI:1215900527
Name:RICCOBONO, CHARLES ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:RICCOBONO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PROSPECT AVE
Mailing Address - Street 2:SUITE 915
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-342-9119
Mailing Address - Fax:201-342-3735
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 915
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:201-342-9119
Practice Address - Fax:201-342-3735
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA24007207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1415301Medicaid
NJ1415301Medicaid
RI434024Medicare ID - Type Unspecified