Provider Demographics
NPI:1700876190
Name:MICKELSON, JUDITH K (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:K
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 TRAIL CREEK CT
Mailing Address - Street 2:
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7594
Mailing Address - Country:US
Mailing Address - Phone:513-543-0595
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-078636174400000X, 207RC0000X
MEMD24100174400000X
MO2017039388207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
060068472OtherRAILROAD MEDICARE
OH2209176Medicaid
OH2209176Medicaid
MI4030573Medicare PIN