Healthcare Provider Details

I. General information

NPI: 1750413464
Provider Name (Legal Business Name): ANTONIO CICCONE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 JORALEMON ST
BELLEVILLE NJ
07109-1455
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: 973-751-2060
  • Fax: 973-751-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MB05752300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04283
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number210336
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB05752300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: