Healthcare Provider Details

I. General information

NPI: 1710988241
Provider Name (Legal Business Name): JOHN JOSEPH MICKEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
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:
Title or Position:
Credential:
Phone: