Basic Information
| Provider Information | |||||||||
| NPI: | 1295787901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKOLS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 COLUMBUS AVE | ||||||||
| Address2: | STE 140 | ||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487086469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893774550 | ||||||||
| FaxNumber: | 9898948544 | ||||||||
| Practice Location | |||||||||
| Address1: | 3009 N SAGINAW RD | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486404555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896331350 | ||||||||
| FaxNumber: | 9896331355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301061523 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4923479 | 05 | MI | MEDICAID | P00392238 | 01 | MI | MEDICARE RAILROAD CARRIER | OTHER |