Healthcare Provider Details

I. General information

NPI: 1952315632
Provider Name (Legal Business Name): TODD A BICKMORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 W MAIN ST
AVON CT
06001-4357
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HARTFORD HEALTHCARE-CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-777-1280
  • Fax: 860-777-1276
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001400
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001400
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053911
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT196278
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51497
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: