Provider Demographics
NPI:1871538132
Name:ERRICO, CHARLES A (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:ERRICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2253 W MASON ST STE 100
Mailing Address - Street 2:PO BOX 13097
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3097
Mailing Address - Country:US
Mailing Address - Phone:920-327-7000
Mailing Address - Fax:920-327-7005
Practice Address - Street 1:2253 W MASON ST STE 100
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7000
Practice Address - Fax:920-327-7005
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI17948207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30875300Medicaid
WI180034994OtherRAILROAD
MI104389413Medicaid
MI105176366Medicaid
WIB52661Medicare UPIN
WI004007650Medicare ID - Type Unspecified