Provider Demographics
NPI:1073543039
Name:SANICOLA, CHARLES PETER (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PETER
Last Name:SANICOLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 MILL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6138
Mailing Address - Country:US
Mailing Address - Phone:301-790-2270
Mailing Address - Fax:301-790-2327
Practice Address - Street 1:372 MILL ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6138
Practice Address - Country:US
Practice Address - Phone:301-790-2270
Practice Address - Fax:301-790-2327
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD470213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405775900OtherDME MEDICAID
MD368998100Medicaid
MDT59623Medicare UPIN
MD405775900OtherDME MEDICAID