Healthcare Provider Details

I. General information

NPI: 1639180607
Provider Name (Legal Business Name): DANA CAVICKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 LATHROP ROAD
PLAINFIELD CT
06374
US

IV. Provider business mailing address

12 LATHROP ROAD
PLAINFIELD CT
06374
US

V. Phone/Fax

Practice location:
  • Phone: 860-564-6293
  • Fax: 860-564-4879
Mailing address:
  • Phone: 860-564-6293
  • Fax: 860-564-4879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number041058
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010041058CT01
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerANTHEM BLUE SHIELF
# 2
IdentifierP3099896
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerOXFORD
# 3
Identifier001410589
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 4
Identifier2V3866
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerHEALTHNET
# 5
Identifier041058
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerCONNECTICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: