Provider Demographics
NPI:1619190055
Name:R DANIEL DAVIS & MARK SCHICKLER FAMILY PODIATRY CENTER
Entity Type:Organization
Organization Name:R DANIEL DAVIS & MARK SCHICKLER FAMILY PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SCHICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-334-6955
Mailing Address - Street 1:2409 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5324
Mailing Address - Country:US
Mailing Address - Phone:203-334-6955
Mailing Address - Fax:203-334-2851
Practice Address - Street 1:2409 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5324
Practice Address - Country:US
Practice Address - Phone:203-334-6955
Practice Address - Fax:203-334-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00195Medicare PIN