Provider Demographics
NPI:1265491674
Name:DICESARE, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:DICESARE
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 1:44 STILES RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079
Mailing Address - Country:US
Mailing Address - Phone:603-893-3548
Mailing Address - Fax:603-898-4779
Practice Address - Street 1:44 STILES RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079
Practice Address - Country:US
Practice Address - Phone:603-893-3548
Practice Address - Fax:603-898-4779
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH127842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH794877OtherMVP PIN
NH30205115Medicaid
NH01Y008391NH01OtherANTHEM ACES #
NH2042889OtherCIGNA BH PIN
NH30205115Medicaid
NHRE8334Medicare ID - Type Unspecified