Healthcare Provider Details

I. General information

NPI: 1568462133
Provider Name (Legal Business Name): GENE CAICCO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/07/2006

III. Provider practice location address

11900 E 12 MILE RD SUITE 102
WARREN MI
48093-3400
US

IV. Provider business mailing address

11900 E 12 MILE RD SUITE 102
WARREN MI
48093-3400
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-7470
  • Fax: 586-573-0850
Mailing address:
  • Phone: 586-573-7470
  • Fax: 586-573-0850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberGC001745
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: