Healthcare Provider Details

I. General information

NPI: 1164750139
Provider Name (Legal Business Name): MARC STEVEN MICOZZI MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 CHASE AVE
BETHESDA MD
20814-3525
US

IV. Provider business mailing address

4605 CHASE AVE
BETHESDA MD
20814-3525
US

V. Phone/Fax

Practice location:
  • Phone: 301-654-4706
  • Fax:
Mailing address:
  • Phone: 301-654-4706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberD0033526
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: