Provider Demographics
NPI:1578535183
Name:DECICCO, JOHN J (D P M PC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:DECICCO
Suffix:
Gender:M
Credentials:D P M PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4966
Mailing Address - Country:US
Mailing Address - Phone:516-681-8866
Mailing Address - Fax:516-681-8890
Practice Address - Street 1:875 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4966
Practice Address - Country:US
Practice Address - Phone:516-681-8866
Practice Address - Fax:516-681-8890
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0030071213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS198OtherOXFORD
NY00416064Medicaid
AS198OtherOXFORD
NY0695930001Medicare NSC
NYT50930Medicare UPIN
NY00416064Medicaid