Provider Demographics
NPI:1730177734
Name:MICKLE, THEODORE ARTHUR JR (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ARTHUR
Last Name:MICKLE
Suffix:JR
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 NW 143RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1725
Mailing Address - Country:US
Mailing Address - Phone:405-748-3925
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-736-2305
Practice Address - Fax:405-456-1623
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine