Healthcare Provider Details

I. General information

NPI: 1639356389
Provider Name (Legal Business Name): RAYMOND J MIKELIONIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W. LATTIN STREET
HASTINGS FL
32145-4111
US

IV. Provider business mailing address

1302 RIVER ST
PALATKA FL
32177-5042
US

V. Phone/Fax

Practice location:
  • Phone: 904-692-1508
  • Fax: 904-692-1509
Mailing address:
  • Phone: 386-328-0108
  • Fax: 386-325-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME138012
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG21006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: