Provider Demographics
NPI:1588869424
Name:TICKOO, SUMIT (MD)
Entity type:Individual
Prefix:
First Name:SUMIT
Middle Name:
Last Name:TICKOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06870
Mailing Address - Country:US
Mailing Address - Phone:203-739-7436
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44573207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT02289243OtherCOVENTRY/FIRST HEALTH
CT044573OtherCONNECTICARE
CT9244670OtherAETNA
0-625-499-9OtherECFMG CERTIFICATE #
CT008032248Medicaid
CT7196206OtherCIGNA
CTP4525993OtherOXFORD
CT010044573CT05OtherANTHEM BCBS CT
CT1167116OtherUSA
CTPENDING CLAIMOtherRR MEDICARE
CT008032248Medicaid