Provider Demographics
NPI:1740376151
Name:MICLAT, MARCIANO I JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARCIANO
Middle Name:I
Last Name:MICLAT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 WINDING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-1018
Mailing Address - Country:US
Mailing Address - Phone:914-636-8657
Mailing Address - Fax:914-636-8427
Practice Address - Street 1:1 WINDING BROOK DR
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-1018
Practice Address - Country:US
Practice Address - Phone:914-636-8657
Practice Address - Fax:914-636-8427
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1254702082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB12880Medicare UPIN
NY319301Medicare ID - Type Unspecified