Provider Demographics
NPI:1477563294
Name:MICAN, CAMILLA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLA
Middle Name:ANN
Last Name:MICAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E DUNLAP AVE
Mailing Address - Street 2:SUITE 1-475
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2807
Mailing Address - Country:US
Mailing Address - Phone:602-944-0202
Mailing Address - Fax:623-875-8761
Practice Address - Street 1:111 E DUNLAP AVE
Practice Address - Street 2:SUITE 1-475
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2807
Practice Address - Country:US
Practice Address - Phone:602-944-0202
Practice Address - Fax:623-875-8761
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14099208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ24554Medicare ID - Type UnspecifiedMEDICARE #
AZC99983Medicare UPIN