Provider Demographics
NPI:1114956232
Name:MYKLEBUST, ANNA MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:MARIA
Last Name:MYKLEBUST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANNA MARIA
Other - Middle Name:M
Other - Last Name:MYKLEBUST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:W8919 RIPLEY RD
Mailing Address - Street 2:P.O. 629
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523-9011
Mailing Address - Country:US
Mailing Address - Phone:608-423-7400
Mailing Address - Fax:608-423-7400
Practice Address - Street 1:W8919 RIPLEY RD
Practice Address - Street 2:P.O. 629
Practice Address - City:CAMBRIDGE
Practice Address - State:WI
Practice Address - Zip Code:53523-9011
Practice Address - Country:US
Practice Address - Phone:608-423-7400
Practice Address - Fax:608-423-7400
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34650-0202085R0202X
MN515152085R0202X
IA381492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI300088211OtherRAILROAD MEDICARE
WI3195200Medicaid
WI391128616RUOtherJOHN DEERE HEALTH PLAN
WI4873OtherDEAN HEALTH INSURANCE
WI4873OtherDEAN HEALTH INSURANCE