Healthcare Provider Details

I. General information

NPI: 1437133634
Provider Name (Legal Business Name): CHRISANDRA REY SICO-DAVIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 NORTH QUEEN ST
KINSTON NC
28502
US

IV. Provider business mailing address

PO BOX 2429
KINSTON NC
28502-2429
US

V. Phone/Fax

Practice location:
  • Phone: 252-522-0335
  • Fax: 252-522-4016
Mailing address:
  • Phone: 252-522-0335
  • Fax: 252-522-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9701593
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier89130KP
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier130KP
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS OF NC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: