Healthcare Provider Details

I. General information

NPI: 1215906847
Provider Name (Legal Business Name): MICHAEL A MIKUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 VANDEVER AVE
SAN DIEGO CA
92120-3315
US

IV. Provider business mailing address

1455 KETTNER BLVD #2502
SAN DIEGO CA
92101-2438
US

V. Phone/Fax

Practice location:
  • Phone: 800-290-5000
  • Fax:
Mailing address:
  • Phone: 312-286-4723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036107899
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA065118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: