Provider Demographics
NPI:1124130760
Name:RICCI, MARIO Q JR (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:Q
Last Name:RICCI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-4620
Mailing Address - Fax:860-346-9687
Practice Address - Street 1:410 SAYBROOK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-4620
Practice Address - Fax:860-346-9687
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT042523207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I14601Medicare UPIN
CT100000381Medicare ID - Type Unspecified