Provider Demographics
NPI:1184658858
Name:MICELI, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MICELI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:114 W 7TH ST STE 900
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-3013
Mailing Address - Country:US
Mailing Address - Phone:512-838-4264
Mailing Address - Fax:512-838-4264
Practice Address - Street 1:4050 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:612-262-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170343702084P0800X
NJ25MA076434002084P0800X
WI308-3202084P0800X
MN648332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry