MEDICARE: DEBORAH D DEMICCO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	0101-039288	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811978885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH D DEMICCO M.D.

Provider Business Mailing Address
First Line	:	3345 ONE OAK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-2642
Country	:	US
Telephone Number	:	540-989-4424
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 CRYSTAL SPRING AVE SW
Second Line	:	SUITE 301
City	:	ROANOKE
State	:	VA
Zip	:	24014-2462
Country	:	US
Telephone Number	:	540-981-7165
Fax Number	:	540-983-1133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	08/11/2011

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