Provider Demographics
NPI:1811989874
Name:DICICCO, RICHARD LARK (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LARK
Last Name:DICICCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:37840 MEDICAL ARTS CT
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33541-4325
Mailing Address - Country:US
Mailing Address - Phone:813-788-5569
Mailing Address - Fax:813-782-8628
Practice Address - Street 1:508 S HABANA AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4181
Practice Address - Country:US
Practice Address - Phone:813-877-6000
Practice Address - Fax:813-877-6002
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2022-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME90737208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL50968OtherBLUE CROSS BLUE SHIELD FL
FL7683574OtherAETNA HEALTHCARE
FL307206OtherAMERIGROUP
FL307206OtherAMERIGROUP
FL50968OtherBLUE CROSS BLUE SHIELD FL