MEDICARE: DR. RICHARD D. DIBACCO DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist	SC001282L	PA
2	213ER0200X	Radiology Podiatrist	SC001282L	PA
3	213ES0103X	Foot & Ankle Surgery Podiatrist	SC001282L	PA
4	213ES0131X	Foot Surgery Podiatrist	SC001282L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609849934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD D. DIBACCO DPM

Provider Business Mailing Address
First Line	:	4402 PEACH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-864-4874
Fax Number	:	814-864-4877

Provider Business Practice Location Address
First Line	:	4402 PEACH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-864-4874
Fax Number	:	814-864-4877

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	06/30/2010

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