Provider Demographics
NPI:1427283894
Name:DECICCO, DEREK MARIO (MPT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MARIO
Last Name:DECICCO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4209
Mailing Address - Country:US
Mailing Address - Phone:714-382-0673
Mailing Address - Fax:
Practice Address - Street 1:15775 LAGUNA CANYON RD STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3192
Practice Address - Country:US
Practice Address - Phone:714-858-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist