Provider Demographics
NPI:1992039085
Name:GRECO, RICHARD YACKSHAW (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:YACKSHAW
Last Name:GRECO
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 1:601 HARRISON ST APT 210
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6479
Mailing Address - Country:US
Mailing Address - Phone:404-840-8626
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:551-996-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09035400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ#39Medicaid
NJ#39Medicare UPIN
NJ#39Medicare PIN