Healthcare Provider Details

I. General information

NPI: 1215385067
Provider Name (Legal Business Name): CHRISTOPHER CICCARELLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 RILEY RD
CELEBRATION FL
34747-5419
US

IV. Provider business mailing address

65 RILEY RD
CELEBRATION FL
34747-5419
US

V. Phone/Fax

Practice location:
  • Phone: 407-635-3022
  • Fax: 321-203-4624
Mailing address:
  • Phone: 407-635-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD468572
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME138213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: