Provider Demographics
NPI:1477514149
Name:SICILIO, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:SICILIO
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 1:2900 E 29TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2623
Mailing Address - Country:US
Mailing Address - Phone:979-776-8440
Mailing Address - Fax:877-601-5854
Practice Address - Street 1:2900 E 29TH ST STE 200
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2623
Practice Address - Country:US
Practice Address - Phone:979-776-8440
Practice Address - Fax:877-601-5854
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130312513Medicaid
TX84E416OtherBLUE SHIELD
TX1303125-02Medicaid
TX370017626OtherRR/MEDICARE
TX1303125-03OtherCSHCN
TX370017626OtherRR/MEDICARE
TXB26451Medicare UPIN