Individual
KEVIN J MICKEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
57 WILLOWBROOK BLVD, SUITE 411, WAYNE, NJ 07470-7045
(973) 256-4111
(973) 256-3719
Mailing address
57 WILLOWBROOK BLVD, SUITE 411, WAYNE, NJ 07470-7045
(973) 256-4111
(973) 256-3719
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
25MA05006300
NJ
207WX0110X
Pediatric Ophthalmology and Strabismus Specialist Physician
25MA05006300
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1141708
—
NJ
01
—
25MA05006300
STATE MEDICAL LICENSE
NJ
Enumeration date
06/12/2006
Last updated
04/20/2020
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