Provider Demographics
NPI:1063403210
Name:MIKSCH, JOHN R (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:MIKSCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5419 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2003
Mailing Address - Country:US
Mailing Address - Phone:804-285-7638
Mailing Address - Fax:804-285-2107
Practice Address - Street 1:5419 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2003
Practice Address - Country:US
Practice Address - Phone:804-285-7638
Practice Address - Fax:804-285-2107
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601001234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACG2865OtherMEDICARE RAILROAD
VA410000418Medicare PIN
VACG2865OtherMEDICARE RAILROAD