Provider Demographics
NPI:1174651715
Name:MORRIS L MICKELSON MD PA
Entity Type:Organization
Organization Name:MORRIS L MICKELSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-639-2244
Mailing Address - Street 1:1111 W FRANK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3390
Mailing Address - Country:US
Mailing Address - Phone:936-639-2244
Mailing Address - Fax:936-634-9334
Practice Address - Street 1:1111 W FRANK AVE STE 100
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3390
Practice Address - Country:US
Practice Address - Phone:936-639-2244
Practice Address - Fax:936-634-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0002NDOtherBCBS
TX183860901Medicaid
TXDE2817Medicare PIN
TX00789ZMedicare PIN