Provider Demographics
NPI:1184714586
Name:CICCOTELLI, KRISTINA (MD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CICCOTELLI
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 1:1650 HUNTINGDON PIKE
Mailing Address - Street 2:SUITE 313
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8007
Mailing Address - Country:US
Mailing Address - Phone:215-938-3413
Mailing Address - Fax:215-938-3422
Practice Address - Street 1:821 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006
Practice Address - Country:US
Practice Address - Phone:215-938-3413
Practice Address - Fax:215-938-3122
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049754L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA746920FWJMedicare PIN
F58269Medicare UPIN