Provider Demographics
NPI:1558377465
Name:DIGIACOMO, MICHAEL (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DIGIACOMO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3301
Mailing Address - Country:US
Mailing Address - Phone:510-465-8012
Mailing Address - Fax:510-835-1626
Practice Address - Street 1:445 30TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3301
Practice Address - Country:US
Practice Address - Phone:510-465-8012
Practice Address - Fax:510-835-1626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1909213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E19090OtherMEDI-CAL PROVIDER NUMBER
CAT11093Medicare UPIN
CA000E19090OtherMEDI-CAL PROVIDER NUMBER