Healthcare Provider Details

I. General information

NPI: 1013478650
Provider Name (Legal Business Name): SEBASTIAN ALEJANDRO MIKULIC DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 S 18TH ST STE 210
FERNANDINA BEACH FL
32034-4785
US

IV. Provider business mailing address

PO BOX 746641
ATLANTA GA
30374-6641
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-9108
  • Fax: 904-261-9911
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberOS18647
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS18647
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: