Provider Demographics
NPI:1992910905
Name:ANDERSON, MIKOL ROBERT (DPM)
Entity type:Individual
Prefix:
First Name:MIKOL
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-0932
Mailing Address - Country:US
Mailing Address - Phone:801-553-9568
Mailing Address - Fax:801-553-9562
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 420
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-269-9939
Practice Address - Fax:801-269-9949
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59638310501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1992910905Medicaid
UT1992910905Medicaid