Provider Demographics
NPI:1124198171
Name:MICKEL, TIMOTHY J (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:MICKEL
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 EMERSON
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-387-3474
Mailing Address - Fax:
Practice Address - Street 1:903 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5837
Practice Address - Country:US
Practice Address - Phone:318-388-2050
Practice Address - Fax:318-325-3740
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016654208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAE47696Medicare UPIN