Provider Demographics
NPI:1336105022
Name:DICECCA, CHARLES ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:DICECCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CONGRESS STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-7457
Mailing Address - Fax:617-773-0299
Practice Address - Street 1:300 CONGRESS STREET
Practice Address - Street 2:SUITE308
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-7457
Practice Address - Fax:617-773-0299
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA039257207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2069237Medicaid
MAC20249OtherBCBS
MAC20249OtherBCBS
C20249Medicare ID - Type Unspecified