Basic Information
Provider Information | |||||||||
NPI: | 1265491674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DICESARE | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 44 STILES RD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | NH | ||||||||
PostalCode: | 03079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038933548 | ||||||||
FaxNumber: | 6038984779 | ||||||||
Practice Location | |||||||||
Address1: | 44 STILES RD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | NH | ||||||||
PostalCode: | 03079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038933548 | ||||||||
FaxNumber: | 6038984779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 12784 | NH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 794877 | 01 | NH | MVP PIN | OTHER | 30205115 | 05 | NH |   | MEDICAID | 01Y008391NH01 | 01 | NH | ANTHEM ACES # | OTHER | 2042889 | 01 | NH | CIGNA BH PIN | OTHER |