Provider Demographics
NPI:1437114030
Name:CICCONE, EUGENE M (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:M
Last Name:CICCONE
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 1:40 MOUNTAIN LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5633
Mailing Address - Country:US
Mailing Address - Phone:860-463-1975
Mailing Address - Fax:
Practice Address - Street 1:279 NEW BRITAIN RD
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1395
Practice Address - Country:US
Practice Address - Phone:860-223-3331
Practice Address - Fax:860-225-2430
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030819207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF10795Medicare UPIN