Provider Demographics
NPI:1861490807
Name:PRICOLO, VICTOR E (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:E
Last Name:PRICOLO
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 1:200 MILL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:300B FAUNCE CORNER ROAD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747
Practice Address - Country:US
Practice Address - Phone:508-973-1020
Practice Address - Fax:508-973-1025
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07257208600000X
MA74672208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA110047437AMedicaid
RI9006648Medicaid
LA110047437AMedicaid
RIU400245760Medicare PIN
MA3052761Medicaid