Provider Demographics
NPI:1922173616
Name:MICKELSON, MORRIS L (MD)
Entity Type:Individual
Prefix:
First Name:MORRIS
Middle Name:L
Last Name:MICKELSON
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 1:1111 W FRANK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3303
Mailing Address - Country:US
Mailing Address - Phone:936-639-2244
Mailing Address - Fax:936-634-9334
Practice Address - Street 1:1111 W FRANK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3303
Practice Address - Country:US
Practice Address - Phone:936-639-2244
Practice Address - Fax:936-634-9334
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U3654OtherBCBS INDIVIDUAL PROVIDER
TXP00282962Medicare PIN
TXG14041Medicare UPIN
TX8F1696Medicare PIN