Provider Demographics
NPI:1477855104
Name:JAMES D. MICKLE, JR. MD
Entity Type:Organization
Organization Name:JAMES D. MICKLE, JR. MD
Other - Org Name:CHOLESTEROL STUDIES AND TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MICKLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:610-952-4418
Mailing Address - Street 1:4 CALLE MEDICO
Mailing Address - Street 2:C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4791
Mailing Address - Country:US
Mailing Address - Phone:610-952-4418
Mailing Address - Fax:610-369-2710
Practice Address - Street 1:4 CALLE MEDICO
Practice Address - Street 2:C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4791
Practice Address - Country:US
Practice Address - Phone:610-952-4418
Practice Address - Fax:610-369-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0397261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA502171OtherMEDICARE ID
PAB38961Medicare UPIN