Basic Information
| Provider Information | |||||||||
| NPI: | 1477514149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SICILIO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 E 29TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797768440 | ||||||||
| FaxNumber: | 8776015854 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 E 29TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797768440 | ||||||||
| FaxNumber: | 8776015854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G0115 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 130312513 | 05 | TX | MEDICAID | 84E416 | 01 | TX | BLUE SHIELD | OTHER | 1303125-02 | 05 | TX | MEDICAID | 370017626 | 01 | TX | RR/MEDICARE | OTHER | 1303125-03 | 01 | TX | CSHCN | OTHER |