Provider Demographics
NPI:1689666307
Name:DECONCINI, DINO T (MD)
Entity Type:Individual
Prefix:
First Name:DINO
Middle Name:T
Last Name:DECONCINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 SANTA MONICA BLVD STE 510E
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2160
Mailing Address - Country:US
Mailing Address - Phone:310-828-8531
Mailing Address - Fax:310-829-2711
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:510E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2160
Practice Address - Country:US
Practice Address - Phone:310-828-8531
Practice Address - Fax:310-829-2711
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84439208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85026Medicare UPIN
CAG84439Medicare PIN