Provider Demographics
NPI:1215906847
Name:MIKUS, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:MIKUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 KETTNER BLVD
Mailing Address - Street 2:#2502
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2438
Mailing Address - Country:US
Mailing Address - Phone:312-286-4723
Mailing Address - Fax:
Practice Address - Street 1:4405 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3315
Practice Address - Country:US
Practice Address - Phone:800-290-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107899207Q00000X
CAA065118207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98681Medicare UPIN