Provider Demographics
NPI:1356761779
Name:DICESARE, ROBERT LOUIS
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS
Last Name:DICESARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GREAT RD
Mailing Address - Street 2:6A
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-2711
Mailing Address - Country:US
Mailing Address - Phone:781-275-0054
Mailing Address - Fax:781-541-6058
Practice Address - Street 1:200 GREAT RD
Practice Address - Street 2:6A
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-2711
Practice Address - Country:US
Practice Address - Phone:781-275-0054
Practice Address - Fax:781-541-6058
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1488156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician