Healthcare Provider Details

I. General information

NPI: 1225612930
Provider Name (Legal Business Name): BENJAMIN DAVID SICLARE SAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

5350 BRIDGE ST APT 4305
TAMPA FL
33611-3288
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-1745
  • Fax:
Mailing address:
  • Phone: 912-409-2980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number13965
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: