Provider Demographics
NPI:1104842129
Name:PERRICONE, ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:PERRICONE
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 1:200 W ARBOR DR
Mailing Address - Street 2:MAIL CODE 8892
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9001
Mailing Address - Country:US
Mailing Address - Phone:619-543-7777
Mailing Address - Fax:619-543-2652
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:MAIL CODE 8892
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-7777
Practice Address - Fax:619-543-2652
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65464208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G654640Medicaid
CAF32917Medicare UPIN
CA00G654640Medicaid