Provider Demographics
NPI:1073803508
Name:MIKEL W SKOUSEN DO LTD
Entity Type:Organization
Organization Name:MIKEL W SKOUSEN DO LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:SKOUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-833-5383
Mailing Address - Street 1:457 E 4TH PL
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-7154
Mailing Address - Country:US
Mailing Address - Phone:480-833-5383
Mailing Address - Fax:480-833-5385
Practice Address - Street 1:457 E 4TH PL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-7154
Practice Address - Country:US
Practice Address - Phone:480-833-5383
Practice Address - Fax:480-833-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1213261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47167Medicare UPIN
AZZ146253Medicare PIN