Basic Information
| Provider Information | |||||||||
| NPI: | 1285659623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EDWIN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10415 GRAND RIVER RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481166533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102271020 | ||||||||
| FaxNumber: | 8102274930 | ||||||||
| Practice Location | |||||||||
| Address1: | 10415 GRAND RIVER RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481166533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102271020 | ||||||||
| FaxNumber: | 8102274930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DM007282 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1321520 | 05 | MI | MEDICAID |