Healthcare Provider Details

I. General information

NPI: 1760839187
Provider Name (Legal Business Name): MICAH REJCEK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 07/20/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17TH MEDICAL GROUP 271 FT RICHARDSON AVE
GOODFELLOW AFB TX
76908
US

IV. Provider business mailing address

17TH MEDICAL GROUP 271 FT RICHARDSON AVE
GOODFELLOW AFB TX
76908
US

V. Phone/Fax

Practice location:
  • Phone: 325-654-3634
  • Fax:
Mailing address:
  • Phone: 325-654-3634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1723
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: