1104227818 NPI number — MR. BENJAMIN EVAN FICOCIELLO

Table of content: MR. BENJAMIN EVAN FICOCIELLO (NPI 1104227818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104227818 NPI number — MR. BENJAMIN EVAN FICOCIELLO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FICOCIELLO
Provider First Name:
BENJAMIN
Provider Middle Name:
EVAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1104227818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 S WINCHESTER BLVD STE B110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-3914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2262 HARVARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94306-1351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-758-5339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2014

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: 103K00000X , with the licence number:  1-18-30811 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1004745 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 042611055 . This is a "TAX ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 99618201 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1303287 . This is a "MBHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1303287 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000023532 . This is a "BMC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M18633 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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