Provider Demographics
NPI:1811978885
Name:DEMICCO, DEBORAH D (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:D
Last Name:DEMICCO
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 1:3345 ONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-2642
Mailing Address - Country:US
Mailing Address - Phone:540-989-4424
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW
Practice Address - Street 2:SUITE 301
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2462
Practice Address - Country:US
Practice Address - Phone:540-981-7165
Practice Address - Fax:540-983-1133
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-039288207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5886112Medicaid
VA6027156Medicaid
VA5886112Medicaid
VA000935C19Medicare PIN
VA6027156Medicaid