Provider Demographics
NPI:1366488850
Name:DY-LIACCO, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DY-LIACCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 W LAS POSITAS BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-4000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 W LAS POSITAS BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4000
Practice Address - Country:US
Practice Address - Phone:925-416-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1927692086S0102X, 208600000X, 204F00000X
NC0010-09358208600000X
IDM-16367208600000X
IL036-1004922086S0102X
NY3061342086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCW874AOtherMEDICARE
NC1366488850Medicaid
NC19PD0OtherBCBS OF NC
ILH81792Medicare UPIN