Healthcare Provider Details

I. General information

NPI: 1538666250
Provider Name (Legal Business Name): MICKEY EMMANUEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

1400 IRVING ST NW APT 950
WASHINGTON DC
20010-3531
US

V. Phone/Fax

Practice location:
  • Phone: 407-599-2700
  • Fax:
Mailing address:
  • Phone: 813-843-4793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD049261
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME169582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: