Provider Demographics
NPI:1659377356
Name:CICCONE, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:CICCONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:4125 IRONBOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2666
Practice Address - Country:US
Practice Address - Phone:757-345-2829
Practice Address - Fax:757-345-0644
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101052863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080091377OtherRAILROAD MEDICARE
VA5626072Medicaid
VA080091377OtherRAILROAD MEDICARE
VA080005992Medicare ID - Type Unspecified