Provider Demographics
NPI:1881718807
Name:MICCO, GUY (MD)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:
Last Name:MICCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GAETAN (GUY)
Other - Middle Name:PAUL
Other - Last Name:MICCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:570 UNIVERSITY HALL # 1190
Mailing Address - Street 2:UNIVERSITY OF CALIFORNIA, BERKELEY
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-0001
Mailing Address - Country:US
Mailing Address - Phone:510-643-0667
Mailing Address - Fax:510-841-6929
Practice Address - Street 1:570 UNIVERSITY HALL SPC 1190
Practice Address - Street 2:UNIVERSITY OF CALIFORNIA, BERKELEY
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-1190
Practice Address - Country:US
Practice Address - Phone:510-643-0667
Practice Address - Fax:510-841-6929
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine