Provider Demographics
NPI:1982632634
Name:GENSICKI, EDWARD STANLEY (DPM)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:STANLEY
Last Name:GENSICKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 DIXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-3105
Mailing Address - Country:US
Mailing Address - Phone:203-287-0336
Mailing Address - Fax:203-287-0387
Practice Address - Street 1:1812 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-3105
Practice Address - Country:US
Practice Address - Phone:203-287-0336
Practice Address - Fax:203-287-0387
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00369213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000369-7413OtherCONNECTICARE
CT183481OtherWELLCARE
P778784OtherOXFORD
CT004067245Medicaid
CT030000369CT01OtherANTHEM BC
CTP00369OtherSTATE LICENSE
CT0V1575OtherHEALTH NET
4800009967OtherRR MEDICARE
4800009967OtherRR MEDICARE
P778784OtherOXFORD
CT004067245Medicaid