Provider Demographics
NPI:1629040084
Name:PICCIANO, LAURA S (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:PICCIANO
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 1:100 E. LANCASTER AVE.
Mailing Address - Street 2:SUITE 330 MOB WEST
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3443
Mailing Address - Country:US
Mailing Address - Phone:610-645-6555
Mailing Address - Fax:610-649-4744
Practice Address - Street 1:6100 MAIN STREET
Practice Address - Street 2:THE RIPA CENTER
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4660
Practice Address - Country:US
Practice Address - Phone:856-673-4912
Practice Address - Fax:856-938-2077
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009621L207R00000X
NJ25MB07361900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017809080001Medicaid
PA034476GRZMedicare ID - Type Unspecified
PA0017809080001Medicaid