Healthcare Provider Details

I. General information

NPI: 1477855104
Provider Name (Legal Business Name): JAMES D. MICKLE, JR. MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CALLE MEDICO C
SANTA FE NM
87505-4791
US

IV. Provider business mailing address

4 CALLE MEDICO C
SANTA FE NM
87505-4791
US

V. Phone/Fax

Practice location:
  • Phone: 610-952-4418
  • Fax: 610-369-2710
Mailing address:
  • Phone: 610-952-4418
  • Fax: 610-369-2710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD2008-0397
License Number StateNM

VIII. Authorized Official

Name: DR. JAMES D. MICKLE JR.
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 610-952-4418