Provider Demographics
NPI:1104007095
Name:EUGENE C. CICCARELLI, MD PC
Entity Type:Organization
Organization Name:EUGENE C. CICCARELLI, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDIENT
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CICCARELLI
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:508-771-3203
Mailing Address - Street 1:116 CAMP ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3008
Mailing Address - Country:US
Mailing Address - Phone:508-771-3203
Mailing Address - Fax:508-790-1943
Practice Address - Street 1:116 CAMP ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3008
Practice Address - Country:US
Practice Address - Phone:508-771-3203
Practice Address - Fax:508-790-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25231207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9756175Medicaid
MAM12071OtherMA BLUE SHIELD GROUP #
MAM12071OtherMEDICARE PROVIDER GROUP #
MAM12071OtherMEDICARE PROVIDER GROUP #