Provider Demographics
NPI:1639183445
Name:VISOCCHI, DOMENIC (MSPT)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:VISOCCHI
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIGH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3860
Mailing Address - Country:US
Mailing Address - Phone:781-395-7333
Mailing Address - Fax:781-395-7331
Practice Address - Street 1:5 HIGH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3860
Practice Address - Country:US
Practice Address - Phone:781-395-7333
Practice Address - Fax:781-395-7331
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67923OtherBCBS OF MASS
MA469253OtherTUFTS
MAY6860901OtherMEDICARE P TAN