Provider Demographics
NPI:1639180607
Name:CAVICKE, DANA (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:CAVICKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LATHROP ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374
Mailing Address - Country:US
Mailing Address - Phone:860-564-6293
Mailing Address - Fax:860-564-4879
Practice Address - Street 1:12 LATHROP ROAD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374
Practice Address - Country:US
Practice Address - Phone:860-564-6293
Practice Address - Fax:860-564-4879
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010041058CT01OtherANTHEM BLUE SHIELF
CTP3099896OtherOXFORD
CT001410589Medicaid
CT2V3866OtherHEALTHNET
CT041058OtherCONNECTICARE
CT010041058CT01OtherANTHEM BLUE SHIELF
CT2V3866OtherHEALTHNET
CT80001904Medicare PIN