Provider Demographics
NPI:1750413464
Name:CICCONE, ANTONIO (DO)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:CICCONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-0599
Mailing Address - Country:US
Mailing Address - Phone:973-751-2060
Mailing Address - Fax:973-751-2291
Practice Address - Street 1:727 JORALEMON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1455
Practice Address - Country:US
Practice Address - Phone:973-751-2060
Practice Address - Fax:973-751-2291
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05752300207P00000X, 207Q00000X
KY04283207P00000X
NY210336207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6163700Medicaid
NJ31D0108390OtherCLIA
NJ31D0108390OtherCLIA
F51313 MPFMedicare UPIN