Provider Demographics
NPI:1336118926
Name:MICK, JAMES M (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:MICK
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 1:2120 CENTERPOINTE WEST DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-443-1111
Mailing Address - Fax:928-443-5554
Practice Address - Street 1:2120 CENTERPOINTE WEST DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-443-1111
Practice Address - Fax:928-443-5554
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ258097Medicaid