Provider Demographics
NPI:1922010545
Name:DICICCO, ERIC (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DICICCO
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 1:412 CREAMERY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2551
Mailing Address - Country:US
Mailing Address - Phone:610-594-7590
Mailing Address - Fax:610-594-2625
Practice Address - Street 1:142 WALLACE AVE STE 201
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-2643
Practice Address - Country:US
Practice Address - Phone:610-873-2700
Practice Address - Fax:610-594-2625
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009706L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG87788Medicare UPIN
PA024483Medicare ID - Type Unspecified