Healthcare Provider Details

I. General information

NPI: 1467945337
Provider Name (Legal Business Name): EUGENE P CICARDO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

1444 PETERMAN DR
ALEXANDRIA LA
71301-3432
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2437
  • Fax:
Mailing address:
  • Phone: 318-442-5399
  • Fax: 318-442-1586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberLL52646
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number330702
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: