Healthcare Provider Details

I. General information

NPI: 1154672152
Provider Name (Legal Business Name): MARCIA AMELIA CICCONE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 VERDUGO BLVD STE 413
GLENDALE CA
91208-1468
US

IV. Provider business mailing address

1516 SAN PABLO ST FL 3
LOS ANGELES CA
90033-5313
US

V. Phone/Fax

Practice location:
  • Phone: 818-658-5980
  • Fax: 323-865-0062
Mailing address:
  • Phone: 323-865-3922
  • Fax: 323-865-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberA122851
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA122851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: