Provider Demographics
NPI:1275645335
Name:DICESARO, DANIEL T (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:DICESARO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-0861
Mailing Address - Country:US
Mailing Address - Phone:412-299-3824
Mailing Address - Fax:
Practice Address - Street 1:925 BRODHEAD RD
Practice Address - Street 2:
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-2353
Practice Address - Country:US
Practice Address - Phone:412-299-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007018L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA345882OtherBLUE SHIELD