Provider Demographics
NPI:1508990946
Name:MIKESELL, KEVIN A (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
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 1:2949 CARIE HILL CIR NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2360
Mailing Address - Country:US
Mailing Address - Phone:330-830-6509
Mailing Address - Fax:
Practice Address - Street 1:981 WOOSTER RD
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654-1536
Practice Address - Country:US
Practice Address - Phone:330-674-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004780207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE76513Medicare UPIN