Provider Demographics
NPI:1578577375
Name:MICKATAVAGE, ROBERT CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:MICKATAVAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3020 WESTCHESTER AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577
Mailing Address - Country:US
Mailing Address - Phone:914-967-4400
Mailing Address - Fax:914-967-6416
Practice Address - Street 1:3020 WESTCHESTER AVE
Practice Address - Street 2:STE 101
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577
Practice Address - Country:US
Practice Address - Phone:914-967-4400
Practice Address - Fax:914-967-6416
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-09-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY092072207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WS1186OtherOXFORD
180037724OtherRAILROAD MC
NY00565513Medicaid
B11902Medicare UPIN
NY00565513Medicaid