Provider Demographics
NPI:1871709196
Name:CICUTO, BRYAN (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CICUTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 HIGHLANDS DR STE 300
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7681
Practice Address - Country:US
Practice Address - Phone:717-625-3509
Practice Address - Fax:717-625-4258
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0171242086S0122X
PAOT010894208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029496100006Medicaid