Provider Demographics
NPI:1730140658
Name:ALICANDRI, MARIO F (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:F
Last Name:ALICANDRI
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 1:65 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2246
Mailing Address - Country:US
Mailing Address - Phone:718-979-9333
Mailing Address - Fax:718-980-0408
Practice Address - Street 1:65 ROSE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2246
Practice Address - Country:US
Practice Address - Phone:718-979-9333
Practice Address - Fax:718-980-0408
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02599508Medicaid
I21097Medicare UPIN
NY02599508Medicaid
121097Medicare UPIN