Provider Demographics
NPI:1902850167
Name:DIZIKI, DONNA CLERICI (DO)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:CLERICI
Last Name:DIZIKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ETHEL RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2249
Mailing Address - Country:US
Mailing Address - Phone:732-623-0399
Mailing Address - Fax:732-248-4405
Practice Address - Street 1:16 ETHEL RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2249
Practice Address - Country:US
Practice Address - Phone:732-623-0399
Practice Address - Fax:732-248-4405
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05014400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDI192918Medicare ID - Type Unspecified
NJE13238Medicare UPIN