Provider Demographics
NPI:1104096361
Name:MICKLE, CLINZO P II (MD)
Entity type:Individual
Prefix:DR
First Name:CLINZO
Middle Name:P
Last Name:MICKLE
Suffix:II
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 1:2400 16TH ST NW
Mailing Address - Street 2:APT. 243
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-6646
Mailing Address - Country:US
Mailing Address - Phone:202-332-2802
Mailing Address - Fax:
Practice Address - Street 1:650 PENNSYLVANIA AVE SE
Practice Address - Street 2:SUITE 420
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-4318
Practice Address - Country:US
Practice Address - Phone:202-547-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD036757207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology