Provider Demographics
NPI:1891776399
Name:PICCHIELLO, ANTHONY CARMINE (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:CARMINE
Last Name:PICCHIELLO
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 1:3951 SOUTH NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-763-4484
Mailing Address - Fax:386-763-1288
Practice Address - Street 1:3951 SOUTH NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127
Practice Address - Country:US
Practice Address - Phone:386-763-4484
Practice Address - Fax:386-763-1288
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26244OtherBC/BS
FL277195OtherHEALTHEASE
FL26244Medicare ID - Type Unspecified
FLF91221Medicare UPIN