Provider Demographics
NPI:1831167691
Name:DICARLO, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DICARLO
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 1:2011 E LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7135
Mailing Address - Country:US
Mailing Address - Phone:702-286-6830
Mailing Address - Fax:
Practice Address - Street 1:2662 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2844
Practice Address - Country:US
Practice Address - Phone:702-616-9660
Practice Address - Fax:702-616-9671
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003821363A00000X
NVPA997363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00376993OtherRAILROAD MEDICARE
NV100509907Medicaid
P74804Medicare UPIN
NVP00376993OtherRAILROAD MEDICARE