Provider Demographics
NPI:1891766689
Name:SICA, GREGORY THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
Last Name:SICA
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 1:201 W 17TH ST
Mailing Address - Street 2:APT 9D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-5374
Mailing Address - Country:US
Mailing Address - Phone:617-645-4167
Mailing Address - Fax:
Practice Address - Street 1:201 W 17TH ST
Practice Address - Street 2:APT 9D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-5374
Practice Address - Country:US
Practice Address - Phone:617-645-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170474-12085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3095657Medicaid
NY02194681Medicaid
E97181Medicare UPIN
MAJ12777Medicare PIN
NY608801Medicare PIN