Healthcare Provider Details

I. General information

NPI: 1427684323
Provider Name (Legal Business Name): BRYAN THOMAS CICCARELLI MD, PHD, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PLAINSBORO RD
PLAINSBORO NJ
08536-1913
US

IV. Provider business mailing address

1 PLAINSBORO RD
PLAINSBORO NJ
08536-1913
US

V. Phone/Fax

Practice location:
  • Phone: 609-853-6049
  • Fax: 609-853-7221
Mailing address:
  • Phone: 609-853-6049
  • Fax: 609-853-7221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA12213400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: