Provider Demographics
NPI:1053336263
Name:FICAZZOLA, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FICAZZOLA
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 1:532 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 142
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3672
Mailing Address - Country:US
Mailing Address - Phone:516-931-0041
Mailing Address - Fax:
Practice Address - Street 1:944 N BROADWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1304
Practice Address - Country:US
Practice Address - Phone:914-968-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198500208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01733348Medicaid
NYG45371Medicare UPIN
NY780631Medicare ID - Type Unspecified