Provider Demographics
NPI:1982884334
Name:MIKOL ANDERSON PC
Entity Type:Organization
Organization Name:MIKOL ANDERSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKOL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-269-9939
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-0932
Mailing Address - Country:US
Mailing Address - Phone:801-553-9568
Mailing Address - Fax:801-553-9562
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 420
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-269-9939
Practice Address - Fax:801-269-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59638310501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1992910905Medicaid
UT000061871Medicare PIN