Provider Demographics
NPI:1184862427
Name:DICESARE, JACOB A (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:DICESARE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:BOVARD
Mailing Address - State:PA
Mailing Address - Zip Code:15619-0007
Mailing Address - Country:US
Mailing Address - Phone:724-261-4080
Mailing Address - Fax:724-261-4081
Practice Address - Street 1:438 PELLIS RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-7900
Practice Address - Country:US
Practice Address - Phone:724-261-4080
Practice Address - Fax:724-261-4081
Is Sole Proprietor?:No
Enumeration Date:2009-01-24
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014434207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102533207 0001Medicaid
PA102533207 0001Medicaid