Provider Demographics
NPI:1063145886
Name:CICONINI, LUIS EDUARDO (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EDUARDO
Last Name:CICONINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVENUE, BOX 1229
Mailing Address - Street 2:
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2098
Mailing Address - Country:US
Mailing Address - Phone:718-270-1926
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:11203-2098
Practice Address - Country:US
Practice Address - Phone:718-270-1926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2023-06-27
Deactivation Date:2023-03-13
Deactivation Code:
Reactivation Date:2023-06-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program