Provider Demographics
NPI:1871599688
Name:MICKUS, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MICKUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 S MCCLINTOCK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7381
Mailing Address - Country:US
Mailing Address - Phone:480-820-1133
Mailing Address - Fax:480-820-9292
Practice Address - Street 1:4515 S MCCLINTOCK DR
Practice Address - Street 2:STE 100
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7381
Practice Address - Country:US
Practice Address - Phone:480-820-1133
Practice Address - Fax:480-820-9292
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29941Medicare UPIN
AZ23668Medicare ID - Type Unspecified