Provider Demographics
NPI:1982664249
Name:CICCARELLI, OVLETO W (MD)
Entity type:Individual
Prefix:
First Name:OVLETO
Middle Name:W
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 1:44 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1381
Mailing Address - Country:US
Mailing Address - Phone:802-728-2430
Mailing Address - Fax:802-728-2613
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1381
Practice Address - Country:US
Practice Address - Phone:802-728-2430
Practice Address - Fax:802-728-2613
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010095208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013959Medicaid
CTB83630Medicare UPIN