Provider Demographics
NPI:1871779579
Name:CICALESE, GERARD R (MD)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:R
Last Name:CICALESE
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 1:330 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-5218
Mailing Address - Country:US
Mailing Address - Phone:973-751-4300
Mailing Address - Fax:973-751-7577
Practice Address - Street 1:330 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-5218
Practice Address - Country:US
Practice Address - Phone:973-751-4300
Practice Address - Fax:973-751-7577
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05656100207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5995302Medicaid
NJ5995302Medicaid