Provider Demographics
NPI:1851310080
Name:CIVITELLA, THOMAS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:CIVITELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2595 HARBOR BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6724
Mailing Address - Country:US
Mailing Address - Phone:941-629-3937
Mailing Address - Fax:941-627-2281
Practice Address - Street 1:2595 HARBOR BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6724
Practice Address - Country:US
Practice Address - Phone:941-629-3937
Practice Address - Fax:941-627-2281
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME17673207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08040YMedicare ID - Type Unspecified
FLE11902Medicare UPIN