Provider Demographics
NPI:1548315823
Name:CICERO, MARK XAVIER (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:XAVIER
Last Name:CICERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:JOHN
Other - Last Name:CICERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:84 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-2017
Mailing Address - Country:US
Mailing Address - Phone:757-575-8007
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8900
Practice Address - Country:US
Practice Address - Phone:203-688-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTFELLOWTRAININGLICENS2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine