Provider Demographics
NPI:1639118284
Name:DENEN, MICKEY E (MD)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:E
Last Name:DENEN
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 1:6611 CLYO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2786
Mailing Address - Country:US
Mailing Address - Phone:937-208-7300
Mailing Address - Fax:937-208-7330
Practice Address - Street 1:6611 CLYO RD
Practice Address - Street 2:SUITE A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2786
Practice Address - Country:US
Practice Address - Phone:937-208-7300
Practice Address - Fax:937-208-7330
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.057283208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0823943Medicaid
OH0695153Medicare PIN
OH0823943Medicaid
OH0695152Medicare PIN