Healthcare Provider Details

I. General information

NPI: 1972931426
Provider Name (Legal Business Name): GEORGE R MCMICKLE M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 N TOWN CENTER DR SUITE 318
LAS VEGAS NV
89144-0514
US

IV. Provider business mailing address

653 N TOWN CENTER DR SUITE 318
LAS VEGAS NV
89144-0514
US

V. Phone/Fax

Practice location:
  • Phone: 702-215-6950
  • Fax: 702-215-3377
Mailing address:
  • Phone: 702-215-6950
  • Fax: 702-215-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License NumberNV9367
License Number StateNV

VIII. Authorized Official

Name: GEORGE R MCMICKLE
Title or Position: PRESIDENT
Credential: M D
Phone: 702-215-6950