Provider Demographics
NPI:1215045240
Name:MICKISH, ALAN BART (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:BART
Last Name:MICKISH
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:PO BOX 1429
Mailing Address - Street 2:
Mailing Address - City:EASTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:76448-1429
Mailing Address - Country:US
Mailing Address - Phone:254-629-1744
Mailing Address - Fax:254-629-3904
Practice Address - Street 1:400 W PLUMMER
Practice Address - Street 2:
Practice Address - City:EASTLAND
Practice Address - State:TX
Practice Address - Zip Code:76448
Practice Address - Country:US
Practice Address - Phone:254-629-1744
Practice Address - Fax:254-629-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1210627-01Medicaid
00GH71Medicare ID - Type Unspecified
TX1210627-01Medicaid