Provider Demographics
NPI:1730221714
Name:MICO, MARIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:MICO
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 1:913 MAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-458-8000
Mailing Address - Fax:973-458-8425
Practice Address - Street 1:913 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8540
Practice Address - Country:US
Practice Address - Phone:973-458-8000
Practice Address - Fax:973-458-8425
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08315100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117705702Medicaid
TX117705702Medicaid