Provider Demographics
NPI:1346412962
Name:JOHN J DECICCO D P M PC
Entity type:Organization
Organization Name:JOHN J DECICCO D P M PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DECICCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-681-8866
Mailing Address - Street 1:875 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4942
Mailing Address - Country:US
Mailing Address - Phone:516-681-8866
Mailing Address - Fax:516-681-8890
Practice Address - Street 1:875 OLD COUNTRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4942
Practice Address - Country:US
Practice Address - Phone:516-681-8866
Practice Address - Fax:516-681-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWTW121Medicare PIN