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General NPI Number Information
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NPI Number | 1477855104
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Entity Type | Organization
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Legal Business Name | JAMES D. MICKLE, JR. MD
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Dates
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Enumeration Date | 12/01/2010
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Last Update Date | 12/01/2010
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Provider Practice Location Address
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Address Line | 4 CALLE MEDICO C
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City | SANTA FE
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State | NM
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Zip | 87505-4791
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Country | US
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Telephone | 610-952-4418
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Fax | 610-369-2710
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Provider Business Mailing Address
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Address Line | 4 CALLE MEDICO C
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City | SANTA FE
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State | NM
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Zip | 87505-4791
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Country | US
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Telephone | 610-952-4418
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Fax | 610-369-2710
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DR. JAMES D. MICKLE JR.
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Credential | MD
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Telephone | 610-952-4418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | MD2008-0397
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License Number State | NM
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