Healthcare Provider Details

I. General information

NPI: 1962481937
Provider Name (Legal Business Name): MICHAEL ANTHONY CICERO M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 FAIRVIEW DR
FRANKLIN VA
23851-1247
US

IV. Provider business mailing address

25114 RIVER RUN TRL
ZUNI VA
23898-3202
US

V. Phone/Fax

Practice location:
  • Phone: 757-569-9397
  • Fax:
Mailing address:
  • Phone: 757-562-7838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number010141560
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: