Provider Demographics
NPI:1861500431
Name:MIKKELSEN, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:MIKKELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1401 E TRENT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2902
Mailing Address - Country:US
Mailing Address - Phone:509-747-3147
Mailing Address - Fax:509-747-0020
Practice Address - Street 1:1401 E TRENT AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2902
Practice Address - Country:US
Practice Address - Phone:509-747-3147
Practice Address - Fax:509-747-0020
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD 00027440208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1058536Medicaid
WA340005435OtherRRB
WA52287OtherL&I
WAE72435Medicare UPIN
WA1058536Medicaid