Provider Demographics
NPI:1205884715
Name:MIKESELL, GARY (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
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 1:300 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5612
Mailing Address - Country:US
Mailing Address - Phone:307-324-8494
Mailing Address - Fax:307-324-8496
Practice Address - Street 1:300 3RD ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5612
Practice Address - Country:US
Practice Address - Phone:307-324-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12467A207Q00000X
MIGM012991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4498759Medicaid
MION71910Medicare ID - Type Unspecified
MI4498759Medicaid