Provider Demographics
NPI:1124106133
Name:MICEK, TIMOTHY J (MD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:MICEK
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 1:3964 GOODMAN RD
Mailing Address - Street 2:STE 128
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6494
Mailing Address - Country:US
Mailing Address - Phone:662-420-7350
Mailing Address - Fax:662-874-5214
Practice Address - Street 1:3964 GOODMAN RD E
Practice Address - Street 2:SUITE 128
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8761
Practice Address - Country:US
Practice Address - Phone:662-420-7350
Practice Address - Fax:662-874-5214
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64863207X00000X
TNMD0000045338207X00000X
MS23185207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01988867Medicaid
MS01988867Medicaid
GA2021201151Medicare NSC