Healthcare Provider Details

I. General information

NPI: 1720086796
Provider Name (Legal Business Name): GERALD VINCENT CICCARELLO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2098 WANTAGH AVE
WANTAGH NY
11793-3914
US

IV. Provider business mailing address

2098 WANTAGH AVE
WANTAGH NY
11793-3914
US

V. Phone/Fax

Practice location:
  • Phone: 516-781-5225
  • Fax: 516-781-9359
Mailing address:
  • Phone: 516-781-5225
  • Fax: 516-781-9359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number003224
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: