MEDICARE: DR. DENNIS L. PICCONE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	25MB03332700	NJ
2	207Q00000X	Family Medicine Physician	MB033327	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	222725033	OTHER	NJ	TAX ID#
2	19826	OTHER	NJ	AMERIGROUP

General Provider Information

NPI Number	:	1578509394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS L. PICCONE D.O.

Provider Business Mailing Address
First Line	:	9710 VENTNOR AVE
Second Line	:
City	:	MARGATE
State	:	NJ
Zip	:	08402-2223
Country	:	US
Telephone Number	:	609-822-4800
Fax Number	:	609-822-2617

Provider Business Practice Location Address
First Line	:	9710 VENTNOR AVE
Second Line	:
City	:	MARGATE
State	:	NJ
Zip	:	08402-2223
Country	:	US
Telephone Number	:	609-822-4800
Fax Number	:	609-822-2617

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	10/19/2020

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