Provider Demographics
NPI:1720086796
Name:CICCARELLO, GERALD VINCENT (DPM)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:VINCENT
Last Name:CICCARELLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3914
Mailing Address - Country:US
Mailing Address - Phone:516-781-5225
Mailing Address - Fax:516-781-9359
Practice Address - Street 1:2098 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3914
Practice Address - Country:US
Practice Address - Phone:516-781-5225
Practice Address - Fax:516-781-9359
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003224213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00685516Medicaid
NY00685516Medicaid
P34941Medicare PIN