MEDICARE: DR. MICHAEL S MIKULECKY M.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	207X00000X	Orthopaedic Surgery Physician	A90779	CA

General Provider Information

NPI Number	:	1245211507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL S MIKULECKY M.D.

Provider Business Mailing Address
First Line	:	3400 DATA DR
Second Line	:	ATTN CREDENTIALING/PAYER ENROLLMENT
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-7956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2528 SISTER MARY COLUMBA DR
Second Line	:
City	:	RED BLUFF
State	:	CA
Zip	:	96080-4327
Country	:	US
Telephone Number	:	530-528-6100
Fax Number	:	530-528-6196

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

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	07/21/2020

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