MEDICARE: DR. BRIAN MIKOLASKO MD MBA MS

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	207R00000X	Internal Medicine Physician	463951	PA
2	207R00000X	Internal Medicine Physician	149352	CA
3	207R00000X	Internal Medicine Physician	276683	MA
4	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	16379	RI
5	282N00000X	General Acute Care Hospital
6	207R00000X	Internal Medicine Physician	16379	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD463951	OTHER	PA	PENNSYLVANIA STATE BOARD OF MEDICINE
2	A149352	OTHER	CA	THE MEDICAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1346669512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN MIKOLASKO MD MBA MS

Provider Business Mailing Address
First Line	:	2109 HARTFORD AVE
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-3246
Country	:	US
Telephone Number	:	626-319-5932
Fax Number	:

Provider Business Practice Location Address
First Line	:	2109 HARTFORD AVE
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-3246
Country	:	US
Telephone Number	:	626-319-5932
Fax Number	:	626-380-2395

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

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	08/14/2025

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