Healthcare Provider Details

I. General information

NPI: 1689058356
Provider Name (Legal Business Name): LORIN MICKELSEN IV DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4233 GATEWAY BLVD
NEWBURGH IN
47630
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-5786
  • Fax: 812-490-4512
Mailing address:
  • Phone: 812-858-5786
  • Fax: 812-490-4512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number243967
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00433
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07001281A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: