MEDICARE: DR. DAVID MIKOS D.C., P.T., M.C.T.A.

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	225100000X	Physical Therapist	004290	CT
2	111N00000X	Chiropractor	001238	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104826890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID MIKOS D.C., P.T., M.C.T.A.

Provider Business Mailing Address
First Line	:	202 STATE ST
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-2207
Country	:	US
Telephone Number	:	203-239-4274
Fax Number	:	203-239-4290

Provider Business Practice Location Address
First Line	:	202 STATE ST
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-2207
Country	:	US
Telephone Number	:	203-239-4274
Fax Number	:	203-239-4290

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	01/13/2016

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