Provider Demographics
NPI:1336149962
Name:MICKENBERG, JAY MARC (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MARC
Last Name:MICKENBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:M
Other - Last Name:MICKENBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8094 EDWIN RAYNOR BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-6834
Mailing Address - Country:US
Mailing Address - Phone:410-255-0040
Mailing Address - Fax:410-360-4955
Practice Address - Street 1:8094 EDWIN RAYNOR BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6834
Practice Address - Country:US
Practice Address - Phone:410-255-0040
Practice Address - Fax:410-360-4955
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2024-02-21
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MD1053213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT276OtherBC/BS OF MD
MD062308301Medicaid
521617469OtherUNITED HEALTHCARE
B765 001OtherBC/BS FEDERAL
1338463OtherCIGNA PPO/HMO
521617469OtherEMPLOYER HEALTH INSURANCE
521617469OtherCOVENTRY
521617469OtherFIRST HEALTH
521617469OtherMAMSI
521617469OtherTRICARE
217484OtherALLIANCE
521617469OtherEHP
MDB765OtherBLUE CHOICE
217484OtherMDIPA/OPTIMUM CHOICE
480012800OtherRAILROAD MEDICARE
521617469OtherCIGNA HEALTHCARE OPEN ACC
521617469OtherFIDELITY
MD0728330001Medicare NSC
MDT276Medicare PIN
521617469OtherTRICARE