MEDICARE: DR. RICHARD LARK DICICCO M.D.

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
1	208600000X	Surgery Physician	ME90737	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50968	OTHER	FL	BLUE CROSS BLUE SHIELD FL
2	7683574	OTHER	FL	AETNA HEALTHCARE
3	307206	OTHER	FL	AMERIGROUP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811989874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD LARK DICICCO M.D.

Provider Business Mailing Address
First Line	:	37840 MEDICAL ARTS CT
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33541-4325
Country	:	US
Telephone Number	:	813-788-5569
Fax Number	:	813-782-8628

Provider Business Practice Location Address
First Line	:	508 S HABANA AVE
Second Line	:	SUITE 160
City	:	TAMPA
State	:	FL
Zip	:	33609-4181
Country	:	US
Telephone Number	:	813-877-6000
Fax Number	:	813-877-6002

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	01/14/2022

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