Individual
CODY BRAD MICKELSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
601 ELMWOOD AVE, BOX 604, ROCHESTER, NY 14642-0001
(585) 275-1384
(585) 276-0122
Mailing address
274 N MAIN ST, BOX 604, LOGAN, UT 84321-3915
(435) 753-1600
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
9806425-1205
UT
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/06/2009
Last updated
06/16/2016
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