Provider Demographics
NPI:1891757621
Name:PANICCO, RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PANICCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 LANDINGS DRIVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-9408
Mailing Address - Country:US
Mailing Address - Phone:724-941-3020
Mailing Address - Fax:
Practice Address - Street 1:80 LANDINGS DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-9408
Practice Address - Country:US
Practice Address - Phone:724-941-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003143L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000680102004Medicaid
PA108119OtherBLUE CROSS
PA000680102004Medicaid