Provider Demographics
NPI:1760487250
Name:SICILIANO, LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:SICILIANO
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 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:1140 ROUTE 72 W
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2412
Practice Address - Country:US
Practice Address - Phone:609-597-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06394800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7106904Medicaid
NJ890468Medicare ID - Type Unspecified
NJ890468CDYMedicare PIN
G38579Medicare UPIN
NJ890468SA6Medicare PIN
NJ7106904Medicaid
NJ890468CDZMedicare PIN