Provider Demographics
NPI:1972931426
Name:GEORGE R MCMICKLE M D P C
Entity type:Organization
Organization Name:GEORGE R MCMICKLE M D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCMICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:702-215-6950
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:SUITE 318
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-215-6950
Mailing Address - Fax:702-215-3377
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:SUITE 318
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-215-6950
Practice Address - Fax:702-215-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV9367261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2018497Medicaid
NVG40365Medicare UPIN