Provider Demographics
NPI:1417987686
Name:MICKELSEN, BRANDON C (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:C
Last Name:MICKELSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BENCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2073
Mailing Address - Country:US
Mailing Address - Phone:208-238-1000
Mailing Address - Fax:208-238-0009
Practice Address - Street 1:1951 BENCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2073
Practice Address - Country:US
Practice Address - Phone:208-238-1000
Practice Address - Fax:208-238-0009
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11004491Medicare PIN