Healthcare Provider Details

I. General information

NPI: 1700197522
Provider Name (Legal Business Name): JAMES JORDAN DICICCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100
APO AE
09180-3100
US

IV. Provider business mailing address

1101 WASHINGTON AVE UNIT 312
PHILADELPHIA PA
19147-3849
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-5868
  • Fax:
Mailing address:
  • Phone: 856-520-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberQ7684
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101251489
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA12468500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: