Provider Demographics
NPI:1578706396
Name:MOMPREMIER, MIKELSON (MD,FACS)
Entity type:Individual
Prefix:DR
First Name:MIKELSON
Middle Name:
Last Name:MOMPREMIER
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N HAMPTON RD STE 290
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8300
Mailing Address - Country:US
Mailing Address - Phone:469-687-5664
Mailing Address - Fax:469-317-3344
Practice Address - Street 1:1510 N HAMPTON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8300
Practice Address - Country:US
Practice Address - Phone:469-687-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7164207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP0198400OtherDPS
TXP7164OtherMEDICAL LICENSE
TXP7164OtherMEDICAL LICENSE