Provider Demographics
NPI:1992050074
Name:FUSON, MICKEY A (DC)
Entity type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:A
Last Name:FUSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 E WASHINGTON ST STE F
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1609
Mailing Address - Country:US
Mailing Address - Phone:309-838-7011
Mailing Address - Fax:
Practice Address - Street 1:2415 E WASHINGTON ST
Practice Address - Street 2:SUITE F
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4473
Practice Address - Country:US
Practice Address - Phone:309-838-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004294111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor