Provider Demographics
NPI:1255778924
Name:NICDAO, RODOLFO (PT)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:NICDAO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 N STATE HIGHWAY 161 STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:803 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1125
Practice Address - Country:US
Practice Address - Phone:540-459-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207799225100000X
MD23139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist