Healthcare Provider Details

I. General information

NPI: 1851373641
Provider Name (Legal Business Name): ROBERT H MIKKELSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-8485
  • Fax:
Mailing address:
  • Phone: 920-926-8485
  • Fax: 920-926-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20061
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: