Healthcare Provider Details

I. General information

NPI: 1740451152
Provider Name (Legal Business Name): LAWRENCE ANGELO CICCHIELLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST RADIOLOGIC ASSOCIATES, PC
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST RADIOLOGIC ASSOCIATES, PC
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-1258
  • Fax: 845-343-0617
Mailing address:
  • Phone: 845-333-1258
  • Fax: 845-343-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number240450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: