Provider Demographics
NPI:1881678118
Name:MICELI, MARK (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MICELI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 LEE ANN DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2911
Mailing Address - Country:US
Mailing Address - Phone:704-547-0000
Mailing Address - Fax:704-547-0460
Practice Address - Street 1:603 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3432
Practice Address - Country:US
Practice Address - Phone:704-867-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC302213E00000X, 213ES0103X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
341408479OtherUHC
NC890183PMedicaid
0004118131OtherAETNA
0807MOtherBCBS
NC2432861AMedicare ID - Type Unspecified