Provider Demographics
NPI:1063940187
Name:DICHOSO, TRAVIS J (DO)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:J
Last Name:DICHOSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LEHIGH AVE SUITE 305B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125
Mailing Address - Country:US
Mailing Address - Phone:215-706-3351
Mailing Address - Fax:
Practice Address - Street 1:100 E LEHIGH AVE SUITE 305B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125
Practice Address - Country:US
Practice Address - Phone:215-707-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT0180062084B0040X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry