Provider Demographics
NPI:1396856548
Name:SCHICKLER, MARK ALAN (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SCHICKLER
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 1:2409 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5324
Mailing Address - Country:US
Mailing Address - Phone:203-334-6955
Mailing Address - Fax:203-334-2851
Practice Address - Street 1:2409 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5324
Practice Address - Country:US
Practice Address - Phone:203-334-6955
Practice Address - Fax:203-334-2851
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT174213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
567628OtherAETNA
030000174CT02OtherBLUE SHIELD
001931OtherHEALTHNET
CT4070447Medicaid
567628OtherAETNA
CT4070447Medicaid