Healthcare Provider Details

I. General information

NPI: 1447361449
Provider Name (Legal Business Name): MARY JANE MIKULS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N 175TH ST SUITE 1000
OMAHA NE
68118-3582
US

IV. Provider business mailing address

8401 W DODGE RD SUITE 280
OMAHA NE
68114-3451
US

V. Phone/Fax

Practice location:
  • Phone: 402-955-5437
  • Fax: 402-955-7310
Mailing address:
  • Phone: 402-955-6877
  • Fax: 402-955-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17882
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: