Individual
DR. JAY MARC MICKENBERG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
8094 EDWIN RAYNOR BLVD, SUITE C, PASADENA, MD 21122-6834
(410) 255-0040
(410) 360-4955
Mailing address
8094 EDWIN RAYNOR BLVD, SUITE C, PASADENA, MD 21122-6834
(410) 255-0040
(410) 360-4955
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
1053
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
062308301
—
MD
01
—
1338463
CIGNA PPO/HMO
—
01
—
217484
ALLIANCE
—
01
—
480012800
RAILROAD MEDICARE
—
01
—
521617469
UNITED HEALTHCARE
—
01
—
B765
BLUE CHOICE
MD
01
—
B765 001
BC/BS FEDERAL
—
01
—
T276
BC/BS OF MD
MD
Enumeration date
07/26/2005
Last updated
02/21/2024
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