Provider Demographics
NPI:1730144296
Name:CICCHIELLO, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:CICCHIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY
Practice Address - Street 2:STE 210
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-966-8675
Practice Address - Fax:502-966-8836
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26217208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
2448315000OtherPAD - NMA
KY64262173Medicaid
1193582OtherCHA / NMA
KYP00266880OtherRRMCR - NMA
000000364343OtherANTHEM - NMA
KY000000720334OtherANTHEM - ICC
0724045OtherCIGNA / NMA
50007142OtherPASSPORT - NMA
0000023025FOtherHUMANA / NMA
062447OtherSIHO - NMA
KY000000720334OtherANTHEM - ICC
2448315000OtherPAD - NMA