Healthcare Provider Details

I. General information

NPI: 1679578272
Provider Name (Legal Business Name): LOUIS MICELI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 WILLOWCREEK RD
PORTAGE IN
46368-4423
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-3175
  • Fax: 219-763-3092
Mailing address:
  • Phone: 219-364-3616
  • Fax: 219-364-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02000622
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02000622
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: