Provider Demographics
NPI:1700052685
Name:CICCONE, JEFFREY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:CICCONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 EARLE OVINGTON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3645
Mailing Address - Country:US
Mailing Address - Phone:516-240-2162
Mailing Address - Fax:
Practice Address - Street 1:333 EARLE OVINGTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3645
Practice Address - Country:US
Practice Address - Phone:162-402-1625
Practice Address - Fax:212-517-4481
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242621207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03249034Medicaid
NYA400034516Medicare PIN