Provider Demographics
NPI:1700020591
Name:DAMICO, KAREN MELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:MELISSA
Last Name:DAMICO
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 1:54 N ARCADIAN CIR
Mailing Address - Street 2:APT. #204
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-6911
Mailing Address - Country:US
Mailing Address - Phone:901-238-4698
Mailing Address - Fax:
Practice Address - Street 1:1129 HALE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6373
Practice Address - Country:US
Practice Address - Phone:901-396-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN48756208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528766Medicaid