Provider Demographics
NPI:1629153119
Name:DYCOCO, EDNA J (MD)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:J
Last Name:DYCOCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64979 OLD TWENTY ON ROAD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9619
Mailing Address - Country:US
Mailing Address - Phone:740-432-6628
Mailing Address - Fax:740-432-5531
Practice Address - Street 1:64979 OLD TWENTY ON ROAD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9619
Practice Address - Country:US
Practice Address - Phone:740-432-6628
Practice Address - Fax:740-432-5531
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056228208000000X
NY129969208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1200145OtherUNITED HEALTHCARE
C0006228OtherHEALTH PLAN
000000153673OtherANTHEM
1001723OtherAETNA
OH0803885Medicaid