Healthcare Provider Details

I. General information

NPI: 1871559500
Provider Name (Legal Business Name): CHARLES MICHAEL CAVICCHIO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WAKE ROBIN RD SUITE 203
LINCOLN RI
02865-4241
US

IV. Provider business mailing address

2 WAKE ROBIN RD SUITE 203
LINCOLN RI
02865-4241
US

V. Phone/Fax

Practice location:
  • Phone: 401-312-9999
  • Fax: 401-312-0416
Mailing address:
  • Phone: 401-312-9999
  • Fax: 401-312-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberDPM 206
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDPM 206
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: