Provider Demographics
NPI:1184720013
Name:MICKELSON, CRAIG ROBERTS (OD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ROBERTS
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4331
Mailing Address - Country:US
Mailing Address - Phone:218-681-4747
Mailing Address - Fax:
Practice Address - Street 1:1720 HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4331
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410044422OtherRR MEDICARE
MN140661OtherUCARE
MN457323400Medicaid
71973OtherHEALTH PARTNERS
1026440OtherPREFERRED ONE
MN61B37MIOtherBLUE CROSS BLUE SHIELD
2201140OtherMEDICA
MN3902360001OtherDURABLE MEDICAL EQUIPMENT
T65864Medicare UPIN
MN457323400Medicaid