Provider Demographics
NPI:1790755882
Name:DICUCCIO, NICHOLAS W (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:W
Last Name:DICUCCIO
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:PO BOX 89
Mailing Address - Street 2:930 BELLEFONTE AVE STE 102
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745
Mailing Address - Country:US
Mailing Address - Phone:570-893-5209
Mailing Address - Fax:570-893-5604
Practice Address - Street 1:930 BELLEFONTE AVE
Practice Address - Street 2:STE 102
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745
Practice Address - Country:US
Practice Address - Phone:570-893-5209
Practice Address - Fax:570-893-5604
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011064E208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006400270002Medicaid
PA0006400270002Medicaid
B33859Medicare UPIN