Provider Demographics
NPI:1457309163
Name:LARICCIA, JOANNA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:MARIE
Last Name:LARICCIA
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:PO BOX 52007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0007
Mailing Address - Country:US
Mailing Address - Phone:678-397-0060
Mailing Address - Fax:678-397-0065
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:678-843-7990
Practice Address - Fax:678-843-4969
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057881208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933254Medicaid
AL009933254Medicaid
ALI45516Medicare UPIN