Provider Demographics
NPI:1417279969
Name:MICKLER, GERALD (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:MICKLER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9988 EXPEDITION PL
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4509
Mailing Address - Country:US
Mailing Address - Phone:317-385-1345
Mailing Address - Fax:
Practice Address - Street 1:9500 E 16TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2008
Practice Address - Country:US
Practice Address - Phone:317-532-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ08492081S0010X
IN36001951A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine