Healthcare Provider Details

I. General information

NPI: 1881678118
Provider Name (Legal Business Name): MARK MICELI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 COX RD
GASTONIA NC
28054-3432
US

IV. Provider business mailing address

1022 LEE ANN DR NE
CONCORD NC
28025-2911
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-7388
  • Fax:
Mailing address:
  • Phone: 704-547-0000
  • Fax: 704-547-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number302
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number302
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number302
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number302
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: