Basic Information
| Provider Information | |||||||||
| NPI: | 1578543948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCICERO | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702975700 | ||||||||
| FaxNumber: | 7707181877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 048535 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | 048535 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2993017 | 01 | GA | CIGNA | OTHER | 340868 | 01 | GA | WELLCARE | OTHER | 000864498A | 05 | GA | MEDICAID | 3600108 | 01 | GA | UNITED HEALTHCARE | OTHER | 10045340 | 01 | GA | AMERIGROUP | OTHER | 52702518 | 01 | GA | BCBS | OTHER | 7286112 | 01 | GA | AETNA | OTHER | 830007840 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER |