Basic Information
| Provider Information | |||||||||
| NPI: | 1023495520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITKO | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 DIXMYTH AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452202475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138623562 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 N HALSTED ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733276800 | ||||||||
| FaxNumber: | 7733276877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2015 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0361455820 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36156800 | 05 | IL | MEDICAID |