Provider Demographics
NPI:1285615393
Name:CICCARELLI, CARMINE (MD)
Entity type:Individual
Prefix:DR
First Name:CARMINE
Middle Name:
Last Name:CICCARELLI
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 1:140 HAZARD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4520
Mailing Address - Country:US
Mailing Address - Phone:860-272-2940
Mailing Address - Fax:860-272-2941
Practice Address - Street 1:140 HAZARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4520
Practice Address - Country:US
Practice Address - Phone:860-272-2940
Practice Address - Fax:860-272-2941
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029420207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001294206Medicaid
200000620EMedicare ID - Type Unspecified
A64486Medicare UPIN
CT001294206Medicaid