Healthcare Provider Details

I. General information

NPI: 1417099136
Provider Name (Legal Business Name): MICHAEL J DECICCO MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH ST SUITE 301
GENEVA NY
14456-1561
US

IV. Provider business mailing address

67 KENDALL STREET SUITE 200
CLIFTON SPRINGS NY
14432
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-5353
  • Fax: 315-315-7875
Mailing address:
  • Phone: 315-462-9482
  • Fax: 315-462-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number220674
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number220674
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number220674
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL J DECICCO
Title or Position: OWNER
Credential: MD
Phone: 315-787-5353