Provider Demographics
NPI:1265466130
Name:CICCANTELLI, RICHARD A (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:CICCANTELLI
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 1:158 MAIN ST
Mailing Address - Street 2:UPPER PERKIOMEN PODIATRY
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073
Mailing Address - Country:US
Mailing Address - Phone:215-679-5393
Mailing Address - Fax:215-679-9674
Practice Address - Street 1:158 MAIN ST
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073
Practice Address - Country:US
Practice Address - Phone:215-679-5393
Practice Address - Fax:215-679-9674
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC1300537002213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0060564000OtherKEYSTONE
0060564000OtherPC
PA0800149Medicaid
50056654OtherCAPITAL BC
20008186OtherAMERIHEALTH
442480169OtherRAILROAD MEDICARE
P2659559OtherOXFORD
1300597002OtherCIGNA
T28239Medicare UPIN
79653Medicare ID - Type Unspecified