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NPI Code Detail

MEDICARE: GARY DICANIO DO

MEDICARE: GARY DICANIO DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician210161NY
2207V00000XObstetrics & Gynecology Physician210161NY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1210161OTHERNYLICENSE

General Provider Information

NPI Number : 1770665721
Entity Type Code : Individual
Provider Name (Legal Business Name) : GARY DICANIO DO
Provider Business Mailing Address
First Line : 105 MEDFORD AVE
Second Line :
City : PATCHOGUE
State : NY
Zip : 11772-1223
Country : US
Telephone Number : 631-580-1000
Fax Number : 631-580-0483
Provider Business Practice Location Address
First Line : 105 MEDFORD AVE
Second Line :
City : PATCHOGUE
State : NY
Zip : 11772-1223
Country : US
Telephone Number : 631-580-1000
Fax Number : 631-580-0483
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2006
Last Update Date : 11/03/2025

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