Provider Demographics
NPI:1770665721
Name:DICANIO, GARY (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:DICANIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2780 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2124
Mailing Address - Country:US
Mailing Address - Phone:631-580-1000
Mailing Address - Fax:631-580-0483
Practice Address - Street 1:2780 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2124
Practice Address - Country:US
Practice Address - Phone:631-580-1000
Practice Address - Fax:631-580-0483
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210161207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY210161OtherLICENSE