Healthcare Provider Details

I. General information

NPI: 1295081248
Provider Name (Legal Business Name): ROXANNE CANO MICKELSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROXANNE CANO M.D.

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberP8160
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberM-17464
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberC206957
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: