Provider Demographics
NPI:1922056431
Name:SICILIANO, CARL J (DPM)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:J
Last Name:SICILIANO
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 1:7424 HIGHWAY 64
Mailing Address - Street 2:SUITE 119
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135
Mailing Address - Country:US
Mailing Address - Phone:901-381-2800
Mailing Address - Fax:901-381-2677
Practice Address - Street 1:7424 US HIGHWAY 64
Practice Address - Street 2:STE 119
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135
Practice Address - Country:US
Practice Address - Phone:901-381-2800
Practice Address - Fax:901-381-2677
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0000000422213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00450580OtherMEDICARE ID TYPE UNSPECIFIED
TNP00450580OtherMEDICARE ID TYPE UNSPECIFIED
TN33519761Medicare PIN
1201220001Medicare NSC
TN1201220001Medicare NSC
33519761Medicare PIN