Provider Demographics
NPI:1003915869
Name:MIKESKA, BRETT W (M D)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:W
Last Name:MIKESKA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 OAK ST SE STE 5070
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3975
Mailing Address - Country:US
Mailing Address - Phone:503-561-8565
Mailing Address - Fax:503-561-8560
Practice Address - Street 1:875 OAK ST SE STE 5070
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-561-8565
Practice Address - Fax:503-561-8560
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25552207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023097Medicaid
ORH77190Medicare UPIN
OR130862Medicare ID - Type Unspecified