Provider Demographics
NPI:1588287312
Name:DERICCO, GINA NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:NICOLE
Last Name:DERICCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1847
Mailing Address - Country:US
Mailing Address - Phone:631-848-1847
Mailing Address - Fax:
Practice Address - Street 1:887 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2115
Practice Address - Country:US
Practice Address - Phone:631-727-2858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009244-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist