Provider Demographics
NPI:1497773097
Name:MICKELSON, JOHN G (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:MICKELSON
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 1:3838 12TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2931
Mailing Address - Country:US
Mailing Address - Phone:701-234-4700
Mailing Address - Fax:701-234-4757
Practice Address - Street 1:3838 12TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2931
Practice Address - Country:US
Practice Address - Phone:701-234-4700
Practice Address - Fax:701-234-4757
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34645207Q00000X
ND62052083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E93914Medicare UPIN
NDN25378Medicare PIN