Provider Demographics
NPI:1831201839
Name:DICECCO, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:DICECCO
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 1:200 HIGH SERVICE AVENUE
Mailing Address - Street 2:MARIAN HALL, 2ND FLOOR
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3456
Mailing Address - Fax:401-456-3458
Practice Address - Street 1:200 HIGH SERVICE AVENUE
Practice Address - Street 2:MARION HALL, 2ND FLOOR
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3456
Practice Address - Fax:401-456-3458
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI6289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9000415Medicaid
RIC90043Medicare UPIN
RI119000415Medicare ID - Type Unspecified