Provider Demographics
NPI:1750432399
Name:DECICCO, JAMES (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:DECICCO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699A OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4613
Mailing Address - Country:US
Mailing Address - Phone:631-271-3520
Mailing Address - Fax:631-271-3706
Practice Address - Street 1:699A OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4613
Practice Address - Country:US
Practice Address - Phone:631-271-3520
Practice Address - Fax:631-271-3706
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5410156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00991259Medicaid
NY00991259Medicaid