Provider Demographics
NPI:1629256037
Name:ANDRE CICERON MD
Entity Type:Organization
Organization Name:ANDRE CICERON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CICERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-926-0662
Mailing Address - Street 1:621 BANNING AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1205
Mailing Address - Country:US
Mailing Address - Phone:609-926-0662
Mailing Address - Fax:609-927-8391
Practice Address - Street 1:207 SHORE RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2759
Practice Address - Country:US
Practice Address - Phone:609-926-0662
Practice Address - Fax:609-927-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03235900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0866601Medicaid
NJ0866601Medicaid