Healthcare Provider Details

I. General information

NPI: 1578506101
Provider Name (Legal Business Name): LUKE DAVID CICCHINELLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LOCUST STREET
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 480-242-5177
  • Fax: 252-744-3616
Mailing address:
  • Phone: 252-744-3520
  • Fax: 252-744-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number361
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: