Provider Demographics
NPI:1730255670
Name:DICHOSO, GRACIANO B (MD)
Entity type:Individual
Prefix:DR
First Name:GRACIANO
Middle Name:B
Last Name:DICHOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1216
Mailing Address - Country:US
Mailing Address - Phone:330-948-1555
Mailing Address - Fax:330-948-2676
Practice Address - Street 1:402 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1216
Practice Address - Country:US
Practice Address - Phone:330-948-1555
Practice Address - Fax:330-948-2676
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033396D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0185508Medicaid
OHDI0370791Medicare ID - Type Unspecified
OHC00939Medicare UPIN