Healthcare Provider Details

I. General information

NPI: 1164644183
Provider Name (Legal Business Name): MICHAEL S CICCHETTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COLLEGE PKWY SUITE 100
WILLIAMSVILLE NY
14221-6800
US

IV. Provider business mailing address

100 COLLEGE PKWY SUITE 100
WILLIAMSVILLE NY
14221-6800
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-2047
  • Fax:
Mailing address:
  • Phone: 716-626-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116017375
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number251201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: