Healthcare Provider Details

I. General information

NPI: 1750559597
Provider Name (Legal Business Name): JOSEPH LEO CICCONE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 05/02/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST PH 11
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST PH 11
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5974
  • Fax:
Mailing address:
  • Phone: 212-305-5974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number029930
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number029930
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: