Healthcare Provider Details

I. General information

NPI: 1457458358
Provider Name (Legal Business Name): MIKEL W SKOUSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 E 4TH PLACE
MESA AZ
85203
US

IV. Provider business mailing address

457 E 4TH PL
MESA AZ
85203-7154
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-5383
  • Fax: 480-833-5385
Mailing address:
  • Phone: 480-833-5383
  • Fax: 480-833-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1213
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: