Provider Demographics
NPI:1023335726
Name:MIKELL, JOHN LECRAW (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LECRAW
Last Name:MIKELL
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 1:225 CANDLER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6093
Mailing Address - Country:US
Mailing Address - Phone:912-352-1700
Mailing Address - Fax:912-354-8545
Practice Address - Street 1:225 CANDLER DR STE 100
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6093
Practice Address - Country:US
Practice Address - Phone:912-352-1700
Practice Address - Fax:912-354-8545
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA0733462085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160249AMedicaid