Provider Demographics
NPI:1710988241
Name:MICKEY, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:MICKEY
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 1:110 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2819
Mailing Address - Country:US
Mailing Address - Phone:337-232-2900
Mailing Address - Fax:337-232-2990
Practice Address - Street 1:110 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2819
Practice Address - Country:US
Practice Address - Phone:337-232-2900
Practice Address - Fax:337-232-2990
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14418207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA60054546OtherRR MEDICARE
LA1193411Medicaid
LA1193411Medicaid
LA5K554Medicare PIN