Provider Demographics
NPI:1508894023
Name:C ICCARELLI, KAREN JILL (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:JILL
Last Name:C ICCARELLI
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 1:16605 KENDLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1614
Mailing Address - Country:US
Mailing Address - Phone:301-223-1241
Mailing Address - Fax:301-223-1240
Practice Address - Street 1:16605 KENDLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1614
Practice Address - Country:US
Practice Address - Phone:301-223-1241
Practice Address - Fax:301-223-1240
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401020500Medicaid
MD401020500Medicaid
MD464P902GMedicare PIN