Provider Demographics
NPI:1982803003
Name:NICASIO, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NICASIO
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 1:22 ATWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-4267
Mailing Address - Country:US
Mailing Address - Phone:413-582-4728
Mailing Address - Fax:413-923-9318
Practice Address - Street 1:22 ATWOOD DR
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4267
Practice Address - Country:US
Practice Address - Phone:413-582-4728
Practice Address - Fax:413-923-9318
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234897207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2150697Medicaid
MA2150697Medicaid