Healthcare Provider Details

I. General information

NPI: 1750347423
Provider Name (Legal Business Name): IGNATIUS CYRIAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

664 NICOLLS RD
DEER PARK NY
11729-2722
US

IV. Provider business mailing address

664 NICOLLS RD
DEER PARK NY
11729-2722
US

V. Phone/Fax

Practice location:
  • Phone: 631-667-5897
  • Fax: 631-667-6917
Mailing address:
  • Phone: 631-667-5897
  • Fax: 631-667-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number126456
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: