Provider Demographics
NPI:1043639123
Name:ROBERT V. DIMEGLIO, MD, LLC
Entity Type:Organization
Organization Name:ROBERT V. DIMEGLIO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:DIMEGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-284-4079
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:M-245
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:678-205-8211
Practice Address - Fax:404-554-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042231208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G701717Medicare Oscar/Certification