Provider Demographics
NPI:1891721361
Name:DICROCE, THERESA MARIE (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:DICROCE
Suffix:
Gender:F
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:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:TONASKET
Mailing Address - State:WA
Mailing Address - Zip Code:98855-0541
Mailing Address - Country:US
Mailing Address - Phone:509-486-1749
Mailing Address - Fax:
Practice Address - Street 1:1617 MAIN ST
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:WA
Practice Address - Zip Code:98844-9380
Practice Address - Country:US
Practice Address - Phone:509-476-3631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00044218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8920146Medicare PIN
C63334Medicare UPIN