Provider Demographics
NPI:1699288480
Name:RICCIARDONE DOHERTY, CARLA
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:RICCIARDONE DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 WATERBURY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5320
Mailing Address - Country:US
Mailing Address - Phone:215-341-1684
Mailing Address - Fax:
Practice Address - Street 1:387 WATERBURY HILL RD
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5320
Practice Address - Country:US
Practice Address - Phone:215-341-1684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherSSI