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
—
—
Other
Enumeration date
06/12/2018
Last updated
08/13/2018
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