Healthcare Provider Details

I. General information

NPI: 1225040629
Provider Name (Legal Business Name): LOUIS A. DINICOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

IV. Provider business mailing address

44 S MAIN ST P.O. BOX 2000
RANDOLPH VT
05060-1381
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-2420
  • Fax: 802-728-2613
Mailing address:
  • Phone: 802-728-2420
  • Fax: 802-728-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420005728
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: