Provider Demographics
NPI:1811944309
Name:MICKELWAIT, J SEMMES (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:SEMMES
Last Name:MICKELWAIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ROOSEVELT AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2687
Mailing Address - Country:US
Mailing Address - Phone:360-424-4186
Mailing Address - Fax:360-428-0927
Practice Address - Street 1:1420 ROOSEVELT AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2687
Practice Address - Country:US
Practice Address - Phone:360-424-4186
Practice Address - Fax:360-428-0927
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013676207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124502Medicaid
WAA09009Medicare UPIN