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General NPI Number Information
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NPI Number | 1497773097
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Entity Type | Individual
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Provider Name | JOHN G MICKELSON DO
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Gender | Male
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Dates
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Enumeration Date | 07/18/2006
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Last Update Date | 09/04/2025
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Provider Practice Location Address
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Address Line | 2930 NE WEST DEVILS LAKE RD STE 3
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City | LINCOLN CITY
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State | OR
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Zip | 97367-5195
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Country | US
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Telephone | 541-557-6427
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1189
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City | CORVALLIS
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State | OR
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Zip | 97339-1189
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34645
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 6205
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License Number State | ND
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO226460
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License Number State | OR
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