Provider Demographics
NPI:1164613675
Name:SICLOVAN, CONSTANTIN (M D)
Entity Type:Individual
Prefix:
First Name:CONSTANTIN
Middle Name:
Last Name:SICLOVAN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13613 W CAMINO DEL SOL
Mailing Address - Street 2:STE 5
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-4480
Mailing Address - Country:US
Mailing Address - Phone:623-584-7154
Mailing Address - Fax:623-584-7194
Practice Address - Street 1:14973 W BELL RD STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3878
Practice Address - Country:US
Practice Address - Phone:623-815-2900
Practice Address - Fax:623-583-1319
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ20050Medicare PIN