Provider Demographics
NPI:1528099074
Name:MIKESELL, BRUCE DEVIN (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:DEVIN
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 1:20700 EDITH PEAK RD
Mailing Address - Street 2:
Mailing Address - City:HUSON
Mailing Address - State:MT
Mailing Address - Zip Code:59846-9603
Mailing Address - Country:US
Mailing Address - Phone:406-626-5676
Mailing Address - Fax:
Practice Address - Street 1:107 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2634
Practice Address - Country:US
Practice Address - Phone:406-676-4441
Practice Address - Fax:406-676-0835
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7984207Q00000X, 207QS0010X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G24868Medicare UPIN