Provider Demographics
NPI:1851363030
Name:MICELI, PHILIP ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANTHONY
Last Name:MICELI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130, ACOMA CANONCITO LAGUNA INDIAN
Mailing Address - Street 2:ATTN ACL PROVIDER ENROLLMENT
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5490
Practice Address - Street 1:ACOMA-CANONCITO-LAGUNA INDIAN
Practice Address - Street 2:80B VETERANS BLVD
Practice Address - City:SAN FIDEL
Practice Address - State:NEW MEXICO
Practice Address - Zip Code:87049
Practice Address - Country:UM
Practice Address - Phone:505-552-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1507207R00000X
NC9700670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM320070Medicare Oscar/Certification
NV651280664OtherTAX ID
NM29273269Medicaid
VAD000Medicare UPIN
NV1851363030Medicaid