Healthcare Provider Details

I. General information

NPI: 1215900527
Provider Name (Legal Business Name): CHARLES ANTHONY RICCOBONO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE SUITE 915
HACKENSACK NJ
07601
US

IV. Provider business mailing address

20 PROSPECT AVE SUITE 915
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-9119
  • Fax: 201-342-3735
Mailing address:
  • Phone: 201-342-9119
  • Fax: 201-342-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA24007
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMA24007
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1415301
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: