Provider Demographics
NPI:1366482630
Name:RICIGLIANO, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RICIGLIANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109
Mailing Address - Country:US
Mailing Address - Phone:856-662-0017
Mailing Address - Fax:856-662-6016
Practice Address - Street 1:6705 PARK AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109
Practice Address - Country:US
Practice Address - Phone:856-662-0017
Practice Address - Fax:856-662-6016
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB048807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4761405Medicaid
NJ4761405Medicaid
NJE79667Medicare UPIN