Provider Demographics
NPI:1447256789
Name:RECITAS, TEOFILO P (MD)
Entity type:Individual
Prefix:
First Name:TEOFILO
Middle Name:P
Last Name:RECITAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BIRCHDALE LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4502
Mailing Address - Country:US
Mailing Address - Phone:516-570-0358
Mailing Address - Fax:
Practice Address - Street 1:200 OLD COUNTRY ROAD SUITE 520
Practice Address - Street 2:STE 100
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11115-2501
Practice Address - Country:US
Practice Address - Phone:516-877-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126655-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00888697Medicaid
E36942Medicare UPIN
NY296502Medicare ID - Type Unspecified