Healthcare Provider Details

I. General information

NPI: 1083666036
Provider Name (Legal Business Name): KIMBERLY SUE CICCERO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 PORTLAND WAY NORTH
GALION OH
44833
US

IV. Provider business mailing address

3255 E LIVINGSTON AVE PO BOX 27940
COLUMBUS OH
43227-1923
US

V. Phone/Fax

Practice location:
  • Phone: 419-468-3668
  • Fax: 419-462-5037
Mailing address:
  • Phone: 614-239-9444
  • Fax: 614-239-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003436
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: