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Organization
96TH STREET JUNCTION BLVD MEDICAL PC
Active
Organization
96TH STREET JUNCTION BLVD MEDICAL PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILDER RUCKER MD (OWNER)
(718) 606-1199
Entity
Organization
Contact information
Practice address
5548 96TH ST, CORONA, NY 11368
(718) 606-1199
Mailing address
5548 96TH ST, CORONA, NY 11368-3009
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
06/12/2018
Last updated
08/13/2018
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