Provider Demographics
NPI:1881684942
Name:MIKESELL, SCOTT ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANTHONY
Last Name:MIKESELL
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 1:1001 E SUPERIOR ST
Mailing Address - Street 2:STE. L201
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-3057
Mailing Address - Fax:218-249-3091
Practice Address - Street 1:1001 E SUPERIOR ST
Practice Address - Street 2:STE. L201
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2207
Practice Address - Country:US
Practice Address - Phone:218-249-3057
Practice Address - Fax:218-249-3091
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52837207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1881684942Medicaid
I15497Medicare PIN
IA1881684942Medicaid