Provider Demographics
NPI:1881670081
Name:SIWICKI, ROBERT DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:SIWICKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914A MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-862-4119
Mailing Address - Fax:850-862-5470
Practice Address - Street 1:914A MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6606
Practice Address - Country:US
Practice Address - Phone:850-862-4119
Practice Address - Fax:850-862-5470
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1110213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041128100Medicaid
FLCN7984OtherRAILROAD MEDICARE PALMETTO GBA
FLT55553Medicare UPIN
FL5663950002Medicare NSC
FLCN7984OtherRAILROAD MEDICARE PALMETTO GBA
FL87803YMedicare PIN