Provider Demographics
NPI:1891002572
Name:CICHELLI, EVAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:CICHELLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 LODGE RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4417
Mailing Address - Country:US
Mailing Address - Phone:706-338-4344
Mailing Address - Fax:
Practice Address - Street 1:5800 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1737
Practice Address - Country:US
Practice Address - Phone:706-338-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006109213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA455128844OtherGROUP TAX ID
PA1029003330001Medicaid
PA244137Medicare PIN