Provider Demographics
NPI:1376655712
Name:MICCA, JOSEPH L (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:MICCA
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 1:1938 RAND RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5340
Mailing Address - Country:US
Mailing Address - Phone:770-888-2524
Mailing Address - Fax:
Practice Address - Street 1:1938 RAND RIDGE CT
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5340
Practice Address - Country:US
Practice Address - Phone:770-888-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39179207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00646929CMedicaid
GA110140782OtherMEDICARE RAILROAD
GA11BDKQTMedicare ID - Type Unspecified
GA00646929CMedicaid