Basic Information
| Provider Information | |||||||||
| NPI: | 1508974239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 GEORGIA AVE NW | ||||||||
| Address2: | STE 4308 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028653415 | ||||||||
| FaxNumber: | 2028656876 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028656611 | ||||||||
| FaxNumber: | 2028656212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | MD13015 | DC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 091551300 | 05 | MD | MEDICAID | 07119143 | 05 | VA | MEDICAID | 029900600 | 05 | DC | MEDICAID |