Provider Demographics
NPI:1306816210
Name:CICCI, LEIGH GOODWIN (MD)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:GOODWIN
Last Name:CICCI
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1085 NE GATEWAY CT NE
Practice Address - Street 2:STE 200
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2406
Practice Address - Country:US
Practice Address - Phone:704-403-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13285OtherBCBSNC
NC566000156OtherPRACTICE TAX ID
NC0401765OtherUNITED HEALTH CARE ID
NC13285OtherBCBS ID
NC187217OtherWELLPATH ID
NC802470OtherPARTNERS MCR CHOICE ID
NCC4260OtherMEDCOST ID
NC8913285Medicaid
NC232009OtherMEDICARE OTHER
NC110248481OtherRAILROAD MCR ID
NC7307433OtherAETNA
NCC4260OtherMEDCOST
NC802470OtherPARTNERS MCR CHOICE ID
NC8913285Medicaid
NC2012717AMedicare PIN