Provider Demographics
NPI:1023114238
Name:STAPP, MICKEY DWIGHT (DPM)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:DWIGHT
Last Name:STAPP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2662
Mailing Address - Country:US
Mailing Address - Phone:762-994-0904
Mailing Address - Fax:762-994-0906
Practice Address - Street 1:150 MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2662
Practice Address - Country:US
Practice Address - Phone:762-994-0904
Practice Address - Fax:762-994-0906
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000728213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGDP728OtherSOUTH CAROLINA MEDICAID
GA2700036OtherUNITED HEALTHCARE
GA000660635HMedicaid
GA555655OtherBCBS OF GEORGIA
SCGPD728Medicaid
GA000660635RMedicaid
GA000660635JMedicaid
GA575733OtherAETNA HMO
GA480032189OtherRAILROAD MEDICARE
GA5106049OtherAETNA PPO
GA48SCCGLMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
GA2700036OtherUNITED HEALTHCARE