Provider Demographics
NPI:1336202589
Name:PICCHIETTI, DAVID P (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:PICCHIETTI
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 1:11316 W WADSWORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3367
Mailing Address - Country:US
Mailing Address - Phone:847-872-3456
Mailing Address - Fax:847-872-3557
Practice Address - Street 1:11316 W WADSWORTH ROAD
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-3367
Practice Address - Country:US
Practice Address - Phone:847-872-3456
Practice Address - Fax:847-872-3557
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007199111N00000X
WI2947012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04982014OtherBCBS
ILL81995Medicare ID - Type Unspecified
IL04982014OtherBCBS