Provider Demographics
NPI:1760576516
Name:MICKELSON, IRA (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 AXTELL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-822-6200
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL
Practice Address - Street 2:SUITE 102
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-822-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5304001863207QA0401X
MIIM043839207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160F318220OtherBCBS OF MICHIGAN
MI160F318220OtherBCBS OF MICHIGAN
MIB46469Medicare UPIN
MI118584OtherPREFERRED CHOICES