Provider Demographics
NPI:1588287312
Name:DERICCO, GINA NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:NICOLE
Last Name:DERICCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2185 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3917
Mailing Address - Country:US
Mailing Address - Phone:516-785-3900
Mailing Address - Fax:516-541-4250
Practice Address - Street 1:2185 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3917
Practice Address - Country:US
Practice Address - Phone:516-785-3900
Practice Address - Fax:516-541-4250
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009244-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist