Provider Demographics
NPI:1871621680
Name:DIMICHELE, JOHN MARK (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:DIMICHELE
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 1:1141 N ROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3354
Mailing Address - Country:US
Mailing Address - Phone:252-384-2590
Mailing Address - Fax:252-384-2589
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-384-2590
Practice Address - Fax:252-384-2589
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200092972080A0000X
NC2015-02134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28911OtherBLUE CROSS BLUE SHIELD
VTOVN1356Medicaid