Provider Demographics
NPI:1548327372
Name:MICKAIL, MAMDOUH GIRGIS (MD)
Entity type:Individual
Prefix:MR
First Name:MAMDOUH
Middle Name:GIRGIS
Last Name:MICKAIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0792
Mailing Address - Country:US
Mailing Address - Phone:318-283-8887
Mailing Address - Fax:
Practice Address - Street 1:108 N 16TH ST
Practice Address - Street 2:
Practice Address - City:MER ROUGE
Practice Address - State:LA
Practice Address - Zip Code:71261-9726
Practice Address - Country:US
Practice Address - Phone:318-239-8010
Practice Address - Fax:318-647-3909
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07043R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1358959Medicaid
LA1358959Medicaid
LA53692Medicare ID - Type Unspecified