Provider Demographics
NPI:1790190791
Name:CICCOLARI MICALDI, SUSANNA (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:CICCOLARI MICALDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N MINNEAPOLIS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3127
Mailing Address - Country:US
Mailing Address - Phone:316-293-2647
Mailing Address - Fax:855-476-0305
Practice Address - Street 1:1001 N. MINNEAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3127
Practice Address - Country:US
Practice Address - Phone:316-293-2647
Practice Address - Fax:855-476-0305
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-084022084P0800X, 2084P0804X
KS04-410772084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004664320001Medicaid