Provider Demographics
NPI:1497013767
Name:CICCIA, EILEEN ANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:ANNA
Last Name:CICCIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6043
Mailing Address - Fax:888-463-6898
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED NEPHROLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6043
Practice Address - Fax:888-463-6898
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2019017048208000000X, 2080P0210X, 2080P0210X
IL0361537762080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200028536Medicaid