=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144366311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD J. D'AMICO D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 MARGARET ST
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-324-3074
-----------------------------------------------------
Fax | 518-324-3077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 MARGARET ST
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-596-5070
-----------------------------------------------------
Fax | 518-324-3077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 228208
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------