Provider Demographics
NPI:1639137680
Name:WALICKI, CELESTE L (DO)
Entity Type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:L
Last Name:WALICKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 CAMDEN LOOP
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-1796
Mailing Address - Country:US
Mailing Address - Phone:917-417-9616
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:863-701-2470
Practice Address - Fax:863-701-2474
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183249207Q00000X
FLOS15592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649572Medicaid
NYG02490Medicare UPIN
NY01649572Medicaid