1063145886 NPI number — LUIS EDUARDO CICONINI M.D.

Table of content: LUIS EDUARDO CICONINI M.D. (NPI 1063145886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063145886 NPI number — LUIS EDUARDO CICONINI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CICONINI
Provider First Name:
LUIS
Provider Middle Name:
EDUARDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063145886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/13/2023
NPI Reactivation Date:
06/27/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 CLARKSON AVENUE, BOX 1229
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11203-2098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-270-1926
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 CLARKSON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11203-2098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-270-1926
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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