Provider Demographics
NPI:1609849934
Name:DIBACCO, RICHARD D (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:DIBACCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1358
Mailing Address - Country:US
Mailing Address - Phone:814-864-4874
Mailing Address - Fax:814-864-4877
Practice Address - Street 1:4402 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1358
Practice Address - Country:US
Practice Address - Phone:814-864-4874
Practice Address - Fax:814-864-4877
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001282L213EP1101X, 213ER0200X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000501005-0001Medicaid
PAU06735Medicare UPIN
PA048583Medicare ID - Type UnspecifiedMEDICARE