Healthcare Provider Details

I. General information

NPI: 1689768723
Provider Name (Legal Business Name): JOHN P DICICCO JR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WINTHROP ST
WORCESTER MA
01604
US

IV. Provider business mailing address

10 WINTHROP ST
WORCESTER MA
01604
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-3690
  • Fax:
Mailing address:
  • Phone: 508-752-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN P DICICCO JR.
Title or Position: OWNER
Credential: MD PC
Phone: 508-752-3690