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General NPI Number Information
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NPI Number | 1699749408
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Entity Type | Individual
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Provider Name | JOSEPH MATTHEW MICCHIA JR. DO
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Gender | Male
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Dates
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Enumeration Date | 02/16/2006
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 10500 LIGON MILL RD SUITE 113
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City | WAKE FOREST
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State | NC
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Zip | 27587-6090
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Country | US
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Telephone | 919-570-5705
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Fax | 919-570-5710
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Provider Business Mailing Address
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Address Line | PO BOX 60447
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City | CHARLOTTE
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State | NC
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Zip | 28260-0447
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Country | US
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Telephone | 704-384-7840
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Fax | 704-384-7830
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OS008793L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2005-01578
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License Number State | NC
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