Provider Demographics
NPI:1467480194
Name:CECCHINI, PHILLIP NELSON (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:NELSON
Last Name:CECCHINI
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 1:26795 PORTOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-1713
Mailing Address - Country:US
Mailing Address - Phone:949-829-9403
Mailing Address - Fax:949-829-9422
Practice Address - Street 1:26795 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-1713
Practice Address - Country:US
Practice Address - Phone:949-829-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA54159DMedicare PIN
CAG14375Medicare UPIN
CAWA54159AMedicare PIN