Provider Demographics
NPI:1285632125
Name:DEMICCO, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:DEMICCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 MERCY BLVD
Mailing Address - Street 2:PLAZA D SUITE A-1
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1753
Mailing Address - Country:US
Mailing Address - Phone:912-920-8898
Mailing Address - Fax:912-920-4418
Practice Address - Street 1:11700 MERCY BLVD
Practice Address - Street 2:PLAZA D SUITE A-1
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1753
Practice Address - Country:US
Practice Address - Phone:912-920-8898
Practice Address - Fax:912-920-4418
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG16855Medicaid
GA145002OtherBLUECROSS BLUESHIELD
GA000586539CMedicaid
GA11SCHHKMedicare PIN
C90386Medicare UPIN