Basic Information
| Provider Information | |||||||||
| NPI: | 1932156825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICICCO | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 N DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404600 | ||||||||
| FaxNumber: | 9373394056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34005744D | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0169106 | 05 | OH | MEDICAID | P00263028 | 01 | RR MEDICARE | OTHER | 000000315965 | 01 | OH | BCBS | OTHER |