Individual
MARK MICELI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
603 COX RD, GASTONIA, NC 28054-3432
(704) 867-7388
Mailing address
1022 LEE ANN DR NE, CONCORD, NC 28025-2911
(704) 547-0000
(704) 547-0460
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
302
NC
213EP1101X
Primary Podiatric Medicine Podiatrist
Primary
302
NC
213ES0103X
Foot & Ankle Surgery Podiatrist
302
NC
213ES0131X
Foot Surgery Podiatrist
302
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0004118131
AETNA
—
01
—
0807M
BCBS
—
01
—
341408479
UHC
—
05
—
890183P
—
NC
Enumeration date
11/30/2005
Last updated
08/09/2022
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