Provider Demographics
NPI:1902832686
Name:MICHAELSEN, MARK R (DC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:MICHAELSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S BROADWAY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1676
Mailing Address - Country:US
Mailing Address - Phone:903-593-5200
Mailing Address - Fax:903-535-9412
Practice Address - Street 1:645 S BROADWAY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1676
Practice Address - Country:US
Practice Address - Phone:903-593-5200
Practice Address - Fax:903-535-9412
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5712111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039541001Medicaid
H42EMedicare ID - Type Unspecified
U2270Medicare UPIN