Provider Demographics
NPI:1023028396
Name:PICCONE, MICHELE R (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:PICCONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 E LANCASTER AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1420
Mailing Address - Country:US
Mailing Address - Phone:484-367-7346
Mailing Address - Fax:484-367-7359
Practice Address - Street 1:230 SUGARTOWN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3029
Practice Address - Country:US
Practice Address - Phone:484-367-7346
Practice Address - Fax:484-367-7359
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05469100207W00000X
PAMD034243E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0153125Medicaid