Provider Demographics
NPI:1902833437
Name:RACKIER, LEA (MD)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:RACKIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:R
Other - Last Name:ELIJOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:54 ALLISON WAY
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1829
Mailing Address - Country:US
Mailing Address - Phone:201-261-4395
Mailing Address - Fax:
Practice Address - Street 1:1776 CLAY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7239
Practice Address - Country:US
Practice Address - Phone:718-299-1100
Practice Address - Fax:718-716-7822
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1656682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01822568Medicaid
NYD91982Medicare UPIN
NY01822568Medicaid