Provider Demographics
NPI:1114774239
Name:ZICCARDI, MICHAEL (CPRS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ZICCARDI
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08610-2315
Mailing Address - Country:US
Mailing Address - Phone:609-558-9091
Mailing Address - Fax:
Practice Address - Street 1:1931 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4603
Practice Address - Country:US
Practice Address - Phone:609-578-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ574175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist