Provider Demographics
NPI:1871559500
Name:CAVICCHIO, CHARLES MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:CAVICCHIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2 WAKE ROBIN RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4241
Mailing Address - Country:US
Mailing Address - Phone:401-312-9999
Mailing Address - Fax:401-312-0416
Practice Address - Street 1:2 WAKE ROBIN RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4241
Practice Address - Country:US
Practice Address - Phone:401-312-9999
Practice Address - Fax:401-312-0416
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM 206213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0614890001Medicare NSC
RIT53254Medicare UPIN