Healthcare Provider Details

I. General information

NPI: 1154353100
Provider Name (Legal Business Name): ANTONIO PICON M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

256 MASON AVE
STATEN ISLAND NY
10305-3408
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6398
  • Fax: 718-226-1247
Mailing address:
  • Phone: 718-226-6398
  • Fax: 718-226-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number002594-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: