Provider Demographics
NPI:1720083173
Name:DICELLO, MICHAEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:DICELLO
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 1:1188 N 15TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3290
Mailing Address - Country:US
Mailing Address - Phone:406-582-1111
Mailing Address - Fax:406-582-1112
Practice Address - Street 1:1188 N 15TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3290
Practice Address - Country:US
Practice Address - Phone:406-582-1111
Practice Address - Fax:406-582-1112
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-000-9879207K00000X
MT11976207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01961568Medicaid
NY96G431OtherBCBS NORTHEAST NEW YORK
VT0VN1993Medicaid
VT7525992-001OtherCIGNA
VT03V100OtherMVP
VT48079OtherBLUE CROSS BLUE SHIELD VT
NY96G431OtherBCBS NORTHEAST NEW YORK
NY01961568Medicaid