Provider Demographics
NPI:1952465650
Name:SICA, COLLEEN MARY (OD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARY
Last Name:SICA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4412
Mailing Address - Country:US
Mailing Address - Phone:732-826-5159
Mailing Address - Fax:732-826-2107
Practice Address - Street 1:100 MENLO PARK STE 408
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-826-5159
Practice Address - Fax:732-826-2107
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA0056700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9042709Medicaid
NJ9042709Medicaid
NJ057208YDX9Medicare PIN