Healthcare Provider Details

I. General information

NPI: 1114822343
Provider Name (Legal Business Name): MICHAEL SIMON DIGIACOMO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 THOMAS JOHNSON DR STE 202
FREDERICK MD
21702-4550
US

IV. Provider business mailing address

7 HICKORY CIR
SEWELL NJ
08080-1818
US

V. Phone/Fax

Practice location:
  • Phone: 301-631-6877
  • Fax:
Mailing address:
  • Phone: 201-312-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: