Provider Demographics
NPI:1134135536
Name:CECCONI, RICHARD D (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:CECCONI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1711 S STEPHENSON AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:906-774-0330
Mailing Address - Fax:906-774-2584
Practice Address - Street 1:1711 S STEPHENSON AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:906-774-0330
Practice Address - Fax:906-774-2584
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301047328208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30846000Medicaid
MI1820146Medicaid
WI30846000Medicaid
A74489Medicare UPIN