Healthcare Provider Details

I. General information

NPI: 1699477604
Provider Name (Legal Business Name): ALEXANDRA CICCONE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MONTAUK HWY STE 100
WEST ISLIP NY
11795-4910
US

IV. Provider business mailing address

2 DAISY LN
SMITHTOWN NY
11787-4807
US

V. Phone/Fax

Practice location:
  • Phone: 631-422-4450
  • Fax:
Mailing address:
  • Phone: 631-339-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberP125984
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: