Provider Demographics
NPI:1366418287
Name:IDA, JOSEPH RICHARD (NP)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RICHARD
Last Name:IDA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SEAMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:11570-2429
Mailing Address - Country:US
Mailing Address - Phone:516-724-0537
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:T BLG ROOM 606
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332104-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS91935Medicare UPIN