Provider Demographics
NPI:1295081248
Name:MICKELSON, ROXANNE CANO (MD)
Entity type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:CANO
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ROXANNE
Other - Middle Name:
Other - Last Name:CANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-553-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-17464207Y00000X
TXP8160207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology