MEDICARE: DR. FAUSTO ANTONIO SICARD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	63799	OH

General Provider Information

NPI Number	:	1255398418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAUSTO ANTONIO SICARD MD

Provider Business Mailing Address
First Line	:	1603 SLATE RUN CIR NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-3806
Country	:	US
Telephone Number	:	330-305-9162
Fax Number	:

Provider Business Practice Location Address
First Line	:	4825 MUNSON ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-3614
Country	:	US
Telephone Number	:	330-497-7525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	07/08/2007

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