Healthcare Provider Details

I. General information

NPI: 1538126057
Provider Name (Legal Business Name): MARY CICCARELLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 N ARLINGTON AVE
INDIANAPOLIS IN
46218-3318
US

IV. Provider business mailing address

720 ESKENAZI AVE FOB/3RD FLOOR
INDIANAPOLIS IN
46202-5166
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-5200
  • Fax: 317-554-5247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01039620A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01039620A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: