Provider Demographics
NPI:1568656981
Name:ZICHELLA, MARIO JR (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:ZICHELLA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 N 9TH ST
Mailing Address - Street 2:718
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3121
Mailing Address - Country:US
Mailing Address - Phone:973-879-0509
Mailing Address - Fax:
Practice Address - Street 1:1025 WALNUT STREET
Practice Address - Street 2:SUITE 700
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-3121
Practice Address - Country:US
Practice Address - Phone:973-879-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAGBTQ6ZXW2080N0001X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGBTQ6ZXWOtherPA TRAINING LICENSE NUMBER