MEDICARE: DR. MARCIA AMELIA CICCONE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VX0201X	Gynecologic Oncology Physician	A122851	CA
2	207V00000X	Obstetrics & Gynecology Physician	A122851	CA

General Provider Information

NPI Number	:	1154672152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCIA AMELIA CICCONE MD

Provider Business Mailing Address
First Line	:	1516 SAN PABLO ST FL 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5313
Country	:	US
Telephone Number	:	323-865-3922
Fax Number	:	323-865-0062

Provider Business Practice Location Address
First Line	:	1808 VERDUGO BLVD STE 413
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91208-1468
Country	:	US
Telephone Number	:	818-658-5980
Fax Number	:	323-865-0062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2012
Last Update Date	:	08/20/2020

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