Provider Demographics
NPI:1649238288
Name:MICCO, RICHARD LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
Last Name:MICCO
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 1:1612 WEST STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101
Mailing Address - Country:US
Mailing Address - Phone:724-658-8589
Mailing Address - Fax:724-658-8978
Practice Address - Street 1:1612 WEST STATE ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101
Practice Address - Country:US
Practice Address - Phone:724-658-8589
Practice Address - Fax:724-658-8978
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002758L213E00000X
OH36002247M213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0984073Medicaid
PA410899Medicare ID - Type Unspecified
PA0984073Medicaid