Provider Demographics
NPI:1740471903
Name:SICILIA, VITALIANO (MD)
Entity type:Individual
Prefix:
First Name:VITALIANO
Middle Name:
Last Name:SICILIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 UNION AVE APT 1G
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-3504
Mailing Address - Country:US
Mailing Address - Phone:646-755-0994
Mailing Address - Fax:
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4455
Practice Address - Country:US
Practice Address - Phone:603-569-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0011767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN257490100Medicaid
MN460000314Medicare PIN