Provider Demographics
NPI:1740262930
Name:BRANCACCIO, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BRANCACCIO
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:PO BOX 70688
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-0688
Mailing Address - Country:US
Mailing Address - Phone:410-872-9188
Mailing Address - Fax:410-872-9169
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2180
Practice Address - Country:US
Practice Address - Phone:202-269-7242
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019338207ZP0102X
DCMD6145207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCC62497Medicare UPIN
DC404305M89Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #