=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467715284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRON CLAD MEDICAL DIAGNOSTIC P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3075 VETERANS MEMORIAL HWY SUITE 161
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-648-8860
-----------------------------------------------------
Fax | 631-676-7597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 94
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-0094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-648-8860
-----------------------------------------------------
Fax | 631-676-7597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D.
-----------------------------------------------------
Name | DR. RICHARD DENISE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-648-8860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------