Healthcare Provider Details

I. General information

NPI: 1417279969
Provider Name (Legal Business Name): GERALD MICKLER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 E 16TH ST
INDIANAPOLIS IN
46229-2008
US

IV. Provider business mailing address

19173 ROUDEBUSH BLVD
NOBLESVILLE IN
46060-7632
US

V. Phone/Fax

Practice location:
  • Phone: 317-532-6200
  • Fax:
Mailing address:
  • Phone: 317-385-1345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0849
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001951A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: