Healthcare Provider Details

I. General information

NPI: 1578658720
Provider Name (Legal Business Name): EMANUEL M. DICICCO-BLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 FRENCH ST STE 2300
NEW BRUNSWICK NJ
08901-1935
US

IV. Provider business mailing address

66 WEST GILBERT ST
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7875
  • Fax: 732-235-6620
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberMA54781
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number25MA05478100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: