Provider Demographics
NPI:1013159003
Name:MICKELSEN, CODY BRAD (MD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:BRAD
Last Name:MICKELSEN
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 1:274 N MAIN ST
Mailing Address - Street 2:BOX 604
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 604
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-1384
Practice Address - Fax:585-276-0122
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9806425-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program