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 1:1416 WAINBROOK DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6289
Mailing Address - Country:US
Mailing Address - Phone:706-312-3668
Mailing Address - Fax:706-312-3670
Practice Address - Street 1:1416 WAINBROOK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6289
Practice Address - Country:US
Practice Address - Phone:706-312-3668
Practice Address - Fax:706-312-3670
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-07-03
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
GA000660635JMedicaid
GA575733OtherAETNA HMO
GA2700036OtherUNITED HEALTHCARE
GA480032189OtherRAILROAD MEDICARE
GA5106049OtherAETNA PPO
GA555655OtherBCBS OF GEORGIA
GA000660635HMedicaid
SCGDP728OtherSOUTH CAROLINA MEDICAID
GA4292280003Medicare NSC
SCGDP728OtherSOUTH CAROLINA MEDICAID
GA48SCCGLMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
GA2700036OtherUNITED HEALTHCARE