Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | MD 052905L | PA |
NPI | 1043208044 |
---|---|
Provider Name | David Ciccolella |
First Address | Philadelphia, PA 19182-7783 |
Second Address | Philadelphia, PA 19140-5103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2005 |
Last Update Date | 12/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0014622330001 | (05) | PA |
F12393 | (02) |