Provider Demographics
NPI:1992741409
Name:ICKES, CYNTHIA H (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:H
Last Name:ICKES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MANOR PL
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-1261
Mailing Address - Country:US
Mailing Address - Phone:631-477-2626
Mailing Address - Fax:631-477-2604
Practice Address - Street 1:222 MANOR PL
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1261
Practice Address - Country:US
Practice Address - Phone:631-477-2626
Practice Address - Fax:631-477-2604
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine