Healthcare Provider Details

I. General information

NPI: 1710112453
Provider Name (Legal Business Name): KAEL VAUN MIKESELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 09/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 E BANNER GATEWAY DR.
GILBERT AZ
85234
US

IV. Provider business mailing address

2946 E BANNER GATEWAY DR.
GILBERT AZ
85234
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-6444
  • Fax: 480-256-3682
Mailing address:
  • Phone: 480-256-6444
  • Fax: 480-256-3682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberDO2584
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number012304
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberOT013153
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: