Provider Demographics
NPI:1255501748
Name:EDWARD S. GENSICKI, D.P.M.
Entity Type:Organization
Organization Name:EDWARD S. GENSICKI, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:GENSICKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-287-0336
Mailing Address - Street 1:1812 DIXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-3105
Mailing Address - Country:US
Mailing Address - Phone:203-287-0336
Mailing Address - Fax:203-287-0387
Practice Address - Street 1:1812 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-3105
Practice Address - Country:US
Practice Address - Phone:203-287-0336
Practice Address - Fax:203-287-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00369332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0937020001Medicare NSC