Basic Information
| Provider Information | |||||||||
| NPI: | 1497723845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOCKVAR | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 1070 | ||||||||
| Address2: | ONE GUSTAVE L LEVY PLACE | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122415561 | ||||||||
| FaxNumber: | 2128609737 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 1967511 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01712138 | 05 | NY | MEDICAID |