Provider Demographics
NPI:1538101662
Name:MICKEY, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:MICKEY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:57 WILLOWBROOK BLVD
Mailing Address - Street 2:SUITE 411
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7045
Mailing Address - Country:US
Mailing Address - Phone:973-256-4111
Mailing Address - Fax:973-256-3719
Practice Address - Street 1:57 WILLOWBROOK BLVD
Practice Address - Street 2:SUITE 411
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7045
Practice Address - Country:US
Practice Address - Phone:973-256-4111
Practice Address - Fax:973-256-3719
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-04-20
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA05006300207W00000X, 207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1141708Medicaid
NJ25MA05006300OtherSTATE MEDICAL LICENSE
NJ1141708Medicaid
NJ659150Q5HMedicare PIN