Provider Demographics
NPI:1881733558
Name:MICKLER, AMY KRISTEN (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTEN
Last Name:MICKLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:KRISTEN
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 917368
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-793-0661
Practice Address - Street 1:1106 DRUID RD S
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3846
Practice Address - Country:US
Practice Address - Phone:727-441-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1355642085R0202X
FLME987362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278336300Medicaid
FLP00427228OtherRR MEDICARE
FL90739OtherBCBSFL
FL278336300Medicaid