Healthcare Provider Details

I. General information

NPI: 1538325220
Provider Name (Legal Business Name): COMPREHENSIVE MEDICAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 KING GEORGE RD STE 205
BASKING RIDGE NJ
07920-2817
US

IV. Provider business mailing address

PO BOX 599
ROSELAND NJ
07068-0599
US

V. Phone/Fax

Practice location:
  • Phone: 973-751-2060
  • Fax: 973-751-2291
Mailing address:
  • Phone: 973-493-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB05723
License Number StateNJ

VIII. Authorized Official

Name: DR. ANTONIO CICCONE
Title or Position: OWNER
Credential: DO
Phone: 973-751-2060