Provider Demographics
NPI:1457458358
Name:SKOUSEN, MIKEL W (DO)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:W
Last Name:SKOUSEN
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 1:457 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 PLACE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203
Practice Address - Country:US
Practice Address - Phone:480-833-5383
Practice Address - Fax:480-833-5385
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237190-01Medicaid
D47167Medicare UPIN