Provider Demographics
NPI:1689058356
Name:MICKELSEN, LORIN IV (DPM)
Entity Type:Individual
Prefix:
First Name:LORIN
Middle Name:
Last Name:MICKELSEN
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-858-5786
Mailing Address - Fax:812-490-4512
Practice Address - Street 1:4233 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630
Practice Address - Country:US
Practice Address - Phone:812-858-5786
Practice Address - Fax:812-490-4512
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY243967213E00000X
KY00433213ES0103X
IN07001281A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty