Healthcare Provider Details

I. General information

NPI: 1568656981
Provider Name (Legal Business Name): MARIO ZICHELLA JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 WALNUT STREET SUITE 700
PHILADELPHIA PA
19107-3121
US

IV. Provider business mailing address

9 N 9TH ST 718
PHILADELPHIA PA
19107-3121
US

V. Phone/Fax

Practice location:
  • Phone: 973-879-0509
  • Fax:
Mailing address:
  • Phone: 973-879-0509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberGBTQ6ZXW
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: