Provider Demographics
NPI:1326044744
Name:PICO, MARIA R (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:R
Last Name:PICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 VILLAGE CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9044
Mailing Address - Country:US
Mailing Address - Phone:770-474-5952
Mailing Address - Fax:770-474-1300
Practice Address - Street 1:210 VILLAGE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9044
Practice Address - Country:US
Practice Address - Phone:770-474-5952
Practice Address - Fax:770-474-1300
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA451473OtherBLUE CROSS BLUE SHEILD GA
GAF58701OtherCOVENTRY
GAF58701Medicare UPIN
GA07BDCKHMedicare PIN
GA070005523Medicare PIN