Healthcare Provider Details

I. General information

NPI: 1578543948
Provider Name (Legal Business Name): RICHARD JOHN LOCICERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501-3834
US

IV. Provider business mailing address

4605 BROKEN ARROW PATH
GAINESVILLE GA
30506-7514
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-5700
  • Fax: 770-718-1877
Mailing address:
  • Phone: 678-656-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number048535
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number048535
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: