Healthcare Provider Details

I. General information

NPI: 1538101662
Provider Name (Legal Business Name): KEVIN J MICKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WILLOWBROOK BLVD SUITE 411
WAYNE NJ
07470-7045
US

IV. Provider business mailing address

57 WILLOWBROOK BLVD SUITE 411
WAYNE NJ
07470-7045
US

V. Phone/Fax

Practice location:
  • Phone: 973-256-4111
  • Fax: 973-256-3719
Mailing address:
  • Phone: 973-256-4111
  • Fax: 973-256-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA05006300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number25MA05006300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: