Provider Demographics
NPI:1164644183
Name:CICCHETTI, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:CICCHETTI
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 1:100 COLLEGE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6800
Mailing Address - Country:US
Mailing Address - Phone:716-626-0093
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6800
Practice Address - Country:US
Practice Address - Phone:434-924-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251201208100000X
VA0116017375390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03110469Medicaid
NY03110469Medicaid
NYJ400004001Medicare PIN