Provider Demographics
NPI:1083701965
Name:SICCION, EDUARDO P (MD)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:P
Last Name:SICCION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2724
Mailing Address - Country:US
Mailing Address - Phone:860-794-9348
Mailing Address - Fax:
Practice Address - Street 1:4523 FRUIT ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2724
Practice Address - Country:US
Practice Address - Phone:860-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041916207R00000X
CAC54593208M00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001419168Medicaid
110009393Medicare ID - Type Unspecified
I22785Medicare UPIN