Provider Demographics
NPI:1083666036
Name:CICCERO, KIMBERLY SUE (DPM)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:CICCERO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 E LIVINGSTON AVE
Mailing Address - Street 2:PO BOX 27940
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-1923
Mailing Address - Country:US
Mailing Address - Phone:614-239-9444
Mailing Address - Fax:614-239-1080
Practice Address - Street 1:396 PORTLAND WAY NORTH
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833
Practice Address - Country:US
Practice Address - Phone:419-468-3668
Practice Address - Fax:419-462-5037
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003436213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH986832OtherCOVENTRY
OH7970774OtherAETNA
OH310945970OtherGREAT WEST
OH1366529653OtherMEDICARE NPI
OH1699074393OtherMEDICARE NPI
OH000000252794OtherUNISON
OH000000580187OtherANTHEM
OH2657843Medicaid
OH5340555OtherCIGNA
OH986832OtherFIRST HEALTH NETWORK
OH$$$$$$$$$ 008OtherMEDICAL MUTUAL OF OHIO
OH000000252794OtherUNISON
OH7970774OtherAETNA
OH$$$$$$$$$ 009OtherMEDICAL MUTUAL OF OHIO
OH2657843Medicaid