Provider Demographics
NPI:1487840914
Name:RICCIO, DUSTIN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MICHAEL
Last Name:RICCIO
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 1:1555 LONG POND RD
Mailing Address - Street 2:EMERGENCY CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7070
Mailing Address - Fax:585-723-7075
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:EMERGENCY CENTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7070
Practice Address - Fax:585-723-7075
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245957207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02978467Medicaid
NY02978467Medicaid
NYRB8277/GRP. 70008AMedicare PIN