Healthcare Provider Details

I. General information

NPI: 1669575668
Provider Name (Legal Business Name): MICHAEL FRANK DE MARCO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LAMAR SMITH RD
POPLARVILLE MS
39470
US

IV. Provider business mailing address

101 LAMAR SMITH RD
POPLARVILLE MS
39470-4086
US

V. Phone/Fax

Practice location:
  • Phone: 601-795-9840
  • Fax:
Mailing address:
  • Phone: 601-795-9840
  • Fax: 601-795-9840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36.002457
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number80232
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: