Provider Demographics
NPI:1255530382
Name:MICKEY, JAIMIE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:JAIMIE
Middle Name:LOUISE
Last Name:MICKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13117 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1812
Mailing Address - Country:US
Mailing Address - Phone:727-351-1700
Mailing Address - Fax:727-351-1701
Practice Address - Street 1:13117 66TH ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1812
Practice Address - Country:US
Practice Address - Phone:727-351-1700
Practice Address - Fax:727-351-1701
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000994100Medicaid
FLP00915749OtherMEDICARE RAILROAD PROVIDER NUMBER
FLBR012YMedicare PIN