Healthcare Provider Details

I. General information

NPI: 1518463868
Provider Name (Legal Business Name): KEVIN JAMES CIPRIANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 QUEENS BLVD
REGO PARK NY
11374-4510
US

IV. Provider business mailing address

9525 QUEENS BLVD
REGO PARK NY
11374-4510
US

V. Phone/Fax

Practice location:
  • Phone: 718-925-6238
  • Fax: 929-895-5109
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number91148
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number324640
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: