Provider Demographics
NPI:1194779744
Name:MICKLE, LAURIE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ELIZABETH
Last Name:MICKLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:MICKLE-BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10512 N 110TH EAST AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6636
Mailing Address - Country:US
Mailing Address - Phone:918-376-8901
Mailing Address - Fax:918-376-8939
Practice Address - Street 1:10512 N 110TH EAST AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6636
Practice Address - Country:US
Practice Address - Phone:918-376-8901
Practice Address - Fax:918-376-8939
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090800AMedicaid
243425204Medicare ID - Type Unspecified
OK100090800AMedicaid