Provider Demographics
NPI:1376569707
Name:DIC, JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 DEER PARK AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2700
Mailing Address - Country:US
Mailing Address - Phone:631-243-6690
Mailing Address - Fax:631-595-1502
Practice Address - Street 1:2005 DEER PARK AVE
Practice Address - Street 2:SUITE D
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-2700
Practice Address - Country:US
Practice Address - Phone:631-243-6690
Practice Address - Fax:631-595-1502
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA61688Medicare UPIN
NY26E461Medicare ID - Type Unspecified