Healthcare Provider Details

I. General information

NPI: 1992039085
Provider Name (Legal Business Name): RICHARD YACKSHAW GRECO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

601 HARRISON ST APT 210
HOBOKEN NJ
07030-6479
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2625
  • Fax:
Mailing address:
  • Phone: 404-840-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MB09035400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier#39
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: