Provider Demographics
NPI:1255494753
Name:MICKEY, MICHAEL LEE
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:MICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 E PAGE ST
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-4049
Mailing Address - Country:US
Mailing Address - Phone:850-287-1144
Mailing Address - Fax:
Practice Address - Street 1:13800 OLD GENTILLY RD
Practice Address - Street 2:USCG MEDICAL
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70129-2218
Practice Address - Country:US
Practice Address - Phone:504-253-6506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information