Provider Demographics
NPI:1962481937
Name:CICERO, MICHAEL ANTHONY (M D)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CICERO
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25114 RIVER RUN TRL
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:VA
Mailing Address - Zip Code:23898-3202
Mailing Address - Country:US
Mailing Address - Phone:757-562-7838
Mailing Address - Fax:
Practice Address - Street 1:106 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1247
Practice Address - Country:US
Practice Address - Phone:757-569-9397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010141560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA600010631OtherCIGNA HMO
VA541436003OtherCHAMPUS/TRICARE
VA823584OtherOPTIMA, MAMSI, ALLIANCE,
NC890505GMedicaid
VA67041OtherSENTARA
NC0218FOtherBLUE CROSS
VA3657687OtherCIGNA
VA5244135OtherAETNA
VA048159OtherANTHEM BC & BS
VA006732798Medicaid
VA98764COtherMEDCOST
VAS44171Medicare UPIN
VAC06186Medicare ID - Type Unspecified