=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891776399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY CARMINE PICCHIELLO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 10/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3951 SOUTH NOVA RD
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-763-4484
-----------------------------------------------------
Fax | 386-763-1288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3951 SOUTH NOVA RD
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-763-4484
-----------------------------------------------------
Fax | 386-763-1288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME0067232
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------