Healthcare Provider Details

I. General information

NPI: 1285794370
Provider Name (Legal Business Name): JOHN J MICKEY, MD, APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL DR
LAFAYETTE LA
70503-2819
US

IV. Provider business mailing address

110 HOSPITAL DR
LAFAYETTE LA
70503-2819
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-2900
  • Fax: 337-232-2990
Mailing address:
  • Phone: 337-232-2900
  • Fax: 337-232-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number14418
License Number StateLA

VIII. Authorized Official

Name: KELLY MARIE THOMASSEE
Title or Position: MANAGER
Credential:
Phone: 337-232-2900