Healthcare Provider Details

I. General information

NPI: 1851310080
Provider Name (Legal Business Name): THOMAS R CIVITELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 HARBOR BLVD SUITE 207
PORT CHARLOTTE FL
33952-6724
US

IV. Provider business mailing address

2595 HARBOR BLVD SUITE 207
PORT CHARLOTTE FL
33952-6724
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-3937
  • Fax: 941-627-2281
Mailing address:
  • Phone: 941-629-3937
  • Fax: 941-627-2281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME17673
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: