Healthcare Provider Details

I. General information

NPI: 1265526586
Provider Name (Legal Business Name): ANDRE CICERON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SHORE RD
SOMERS POINT NJ
08244-2759
US

IV. Provider business mailing address

207 SHORE RD
SOMERS POINT NJ
08244-2759
US

V. Phone/Fax

Practice location:
  • Phone: 609-926-5838
  • Fax: 609-926-5839
Mailing address:
  • Phone: 609-926-5838
  • Fax: 609-926-5839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA03235900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: