Provider Demographics
NPI:1841262953
Name:DECICCO, VINCENT L (DO)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:L
Last Name:DECICCO
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 1:8109 RITCHIE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-6917
Mailing Address - Country:US
Mailing Address - Phone:443-270-8600
Mailing Address - Fax:443-270-8990
Practice Address - Street 1:8109 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6917
Practice Address - Country:US
Practice Address - Phone:443-481-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH83333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine