Provider Demographics
NPI:1679666937
Name:DIMICELI, ROBERT MORRIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MORRIS
Last Name:DIMICELI
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 1:666 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:718-965-7188
Mailing Address - Fax:718-768-7739
Practice Address - Street 1:666 10TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4502
Practice Address - Country:US
Practice Address - Phone:718-965-7188
Practice Address - Fax:718-768-7739
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2008-01-25
Deactivation Date:2007-11-20
Deactivation Code:
Reactivation Date:2008-01-25
Provider Licenses
StateLicense IDTaxonomies
NYNOO4223213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0003351OtherGHI PIN
NYP1003380OtherOXFORD PIN
NY00000050014OtherGHI MEDICARE PIN
NY00000050014OtherGHI MEDICARE PIN
NYP1003380OtherOXFORD PIN