MEDICARE: DR. JOHN R. MIKSCH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0601001234	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG2865	OTHER	VA	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1063403210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN R. MIKSCH O.D.

Provider Business Mailing Address
First Line	:	5419 PATTERSON AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-2003
Country	:	US
Telephone Number	:	804-285-7638
Fax Number	:	804-285-2107

Provider Business Practice Location Address
First Line	:	5419 PATTERSON AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-2003
Country	:	US
Telephone Number	:	804-285-7638
Fax Number	:	804-285-2107

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	05/05/2014

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