Provider Demographics
NPI:1841284346
Name:FICCO, CHARLES W (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:FICCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1201
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4550
Mailing Address - Country:US
Mailing Address - Phone:678-381-2020
Mailing Address - Fax:678-381-2015
Practice Address - Street 1:970 SANDERS RD STE 100
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:678-381-2020
Practice Address - Fax:678-381-2015
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT01583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC16012OtherRAILROAD MEDICARE
GA000741815AMedicaid
GA000741815AMedicaid