Provider Demographics
NPI:1992755912
Name:CORDICE-FORD, CANDIDA (MD)
Entity type:Individual
Prefix:
First Name:CANDIDA
Middle Name:
Last Name:CORDICE-FORD
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 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7889
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:11120 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11433
Practice Address - Country:US
Practice Address - Phone:718-206-9888
Practice Address - Fax:718-206-3033
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01991542Medicaid
G99590Medicare UPIN
NYG400033768Medicare PIN