Provider Demographics
NPI:1649256348
Name:ROBERT D. SIWICKI,D.P.M.,P.A.
Entity type:Organization
Organization Name:ROBERT D. SIWICKI,D.P.M.,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SIWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-862-4119
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:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-862-4119
Practice Address - Fax:850-862-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP01110 & P02964213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty