Provider Demographics
NPI:1306015664
Name:GERALD A. CICHOCKI, M.D., PC
Entity Type:Organization
Organization Name:GERALD A. CICHOCKI, M.D., PC
Other - Org Name:TRINIDAD UROLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CICHOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-846-2388
Mailing Address - Street 1:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-0831
Mailing Address - Country:US
Mailing Address - Phone:719-846-2388
Mailing Address - Fax:719-846-7305
Practice Address - Street 1:328 S BONAVENTURE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2086
Practice Address - Country:US
Practice Address - Phone:719-846-2388
Practice Address - Fax:719-846-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43028208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97350818Medicaid
COA77996Medicare UPIN
COC800720Medicare PIN