Provider Demographics
NPI:1578769816
Name:MICKELSON, JOSEPH DALE (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DALE
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOEY
Other - Middle Name:DALE
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-624-2313
Mailing Address - Fax:
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:SUITE 200W
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4880
Practice Address - Country:US
Practice Address - Phone:509-624-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066154A207Q00000X
WAMD60456946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine