Healthcare Provider Details

I. General information

NPI: 1417952433
Provider Name (Legal Business Name): JOHN CARMEN DERCOLA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-528-9926
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: