Provider Demographics
NPI:1457357592
Name:KIKTA, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:KIKTA
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 1:1728 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2763
Mailing Address - Country:US
Mailing Address - Phone:815-227-1068
Mailing Address - Fax:
Practice Address - Street 1:1728 RED OAK LN
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2763
Practice Address - Country:US
Practice Address - Phone:815-227-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360672682086S0127X, 2086S0129X
WI662802086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204575400OtherOWCP
IL194341OtherPERSONAL CARE
IL036067268 2Medicaid
IL194341OtherPERSONAL CARE
ILL89795Medicare PIN
ILF84320Medicare UPIN