MEDICARE: DEMETRIUS ROMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TF0000X	Family Psychologist		GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811474125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRIUS ROMAN

Provider Business Mailing Address
First Line	:	PO BOX 962651
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-6926
Country	:	US
Telephone Number	:	770-282-0389
Fax Number	:

Provider Business Practice Location Address
First Line	:	1580 PHOENIX BLVD STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-5187
Country	:	US
Telephone Number	:	770-282-0389
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	05/11/2026

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Directions to “ DEMETRIUS ROMAN ” Practice Location

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