Provider Demographics
NPI:1730274432
Name:MIKESELL, JERRY FORREST (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:FORREST
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 N ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2932
Mailing Address - Country:US
Mailing Address - Phone:814-238-6097
Mailing Address - Fax:
Practice Address - Street 1:1393 N ATHERTON ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2932
Practice Address - Country:US
Practice Address - Phone:814-238-6097
Practice Address - Fax:814-238-5527
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033134E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB37392Medicare UPIN
PA413750Medicare ID - Type Unspecified