Provider Demographics
NPI:1154353100
Name:PICON, ANTONIO (MD,)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:PICON
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 1:256 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3408
Mailing Address - Country:US
Mailing Address - Phone:718-226-6398
Mailing Address - Fax:718-226-1247
Practice Address - Street 1:256 MASON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:718-226-6398
Practice Address - Fax:718-226-1247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002594-1208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02799622Medicaid
NY02799622Medicaid