Provider Demographics
NPI:1669564175
Name:MIKLUSAK, THOMAS ALAN (MD PHD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN
Last Name:MIKLUSAK
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S LAKE AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101
Mailing Address - Country:US
Mailing Address - Phone:626-792-9949
Mailing Address - Fax:818-952-5360
Practice Address - Street 1:180 S LAKE AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-792-9949
Practice Address - Fax:818-952-5360
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP0814X
CAC353182084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry