Provider Demographics
NPI:1689855546
Name:GERALD CICCARELLO
Entity Type:Organization
Organization Name:GERALD CICCARELLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CICCARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-781-5225
Mailing Address - Street 1:2098 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3914
Mailing Address - Country:US
Mailing Address - Phone:516-781-5225
Mailing Address - Fax:
Practice Address - Street 1:2098 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3914
Practice Address - Country:US
Practice Address - Phone:516-781-5225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4008420001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4008420001Medicare NSC