Provider Demographics
NPI:1376596981
Name:DICIRO, DOMINIC THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:THEODORE
Last Name:DICIRO
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 1:7804 167TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-6323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31881207P00000X
WAMD000045375207PE0004X
MO2012003239207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436651Medicaid
WA8436651Medicaid
WAP00253186Medicare PIN
WA8856566Medicare PIN
CABT842ZMedicare PIN