Provider Demographics
NPI:1225165632
Name:CICCOLO, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:CICCOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3131 LA CANADA ST STE 230
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-2551
Mailing Address - Country:US
Mailing Address - Phone:702-732-1290
Mailing Address - Fax:702-260-1926
Practice Address - Street 1:3131 LA CANADA ST STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-2551
Practice Address - Country:US
Practice Address - Phone:702-732-1290
Practice Address - Fax:702-260-1926
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV9463208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWCLCQOtherGROUP MEDICARE #
NV100500157Medicaid
NV20-18427Medicaid
NV20-18427Medicaid
NV33960Medicare ID - Type Unspecified