Provider Demographics
NPI:1548243579
Name:CICCARELLI, CIRO A (MD)
Entity Type:Individual
Prefix:
First Name:CIRO
Middle Name:A
Last Name:CICCARELLI
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 1:1436 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1405
Mailing Address - Country:US
Mailing Address - Phone:516-563-7245
Mailing Address - Fax:516-563-7295
Practice Address - Street 1:1436 BROADWAY
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1405
Practice Address - Country:US
Practice Address - Phone:516-563-7245
Practice Address - Fax:516-563-7295
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175231207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01091689Medicaid
NY01091689Medicaid
NY28E721Medicare ID - Type Unspecified