Provider Demographics
NPI:1285383877
Name:LASERWAVE PODIATRY
Entity type:Organization
Organization Name:LASERWAVE PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DA
Authorized Official - Last Name:CICERO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:401-363-3150
Mailing Address - Street 1:12 ROOSEVELT AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2842
Mailing Address - Country:US
Mailing Address - Phone:833-527-3798
Mailing Address - Fax:
Practice Address - Street 1:12 ROOSEVELT AVE STE 203
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2842
Practice Address - Country:US
Practice Address - Phone:401-363-3150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-21
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty