Healthcare Provider Details

I. General information

NPI: 1346669512
Provider Name (Legal Business Name): BRIAN MIKOLASKO MD MBA MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 HARTFORD AVE
JOHNSTON RI
02919-3246
US

IV. Provider business mailing address

2109 HARTFORD AVE
JOHNSTON RI
02919-3246
US

V. Phone/Fax

Practice location:
  • Phone: 626-319-5932
  • Fax: 626-380-2395
Mailing address:
  • Phone: 626-319-5932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number463951
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number149352
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number276683
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16379
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number16379
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: