Healthcare Provider Details

I. General information

NPI: 1467431734
Provider Name (Legal Business Name): MARK ROBERT MIKOLS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK ROBERT MIKOLS D.O.

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16850 SE 272ND ST
COVINGTON WA
98042-4931
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 253-395-2006
  • Fax: 253-395-1977
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00002341
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: