Healthcare Provider Details

I. General information

NPI: 1154400406
Provider Name (Legal Business Name): MYRA C RECON-BUCEVIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8268 164TH ST
JAMAICA NY
11432-1121
US

IV. Provider business mailing address

7925 WINCHESTER BLVD MANAGED CARE, D1-01
QUEENS VILLAGE NY
11427-2128
US

V. Phone/Fax

Practice location:
  • Phone: 718-883-3225
  • Fax: 718-883-6193
Mailing address:
  • Phone: 718-264-3950
  • Fax: 718-264-3591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number236892
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: