Provider Demographics
NPI:1396364592
Name:CICCHINELLI, CARISSA (MD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:CICCHINELLI
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 1:229 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3035
Mailing Address - Country:US
Mailing Address - Phone:484-226-6692
Mailing Address - Fax:
Practice Address - Street 1:1100 WALNUT ST STE 601
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-955-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD480664207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program