Healthcare Provider Details

I. General information

NPI: 1467115006
Provider Name (Legal Business Name): DANIELLE DECICCO MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 559-882-2738
  • Fax: 304-598-4871
Mailing address:
  • Phone: 681-342-3457
  • Fax: 304-598-4871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34078
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: