Basic Information
| Provider Information | |||||||||
| NPI: | 1417929431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKAWA | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 HOSPITAL AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143752070 | ||||||||
| FaxNumber: | 8143752076 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523962 | ||||||||
| FaxNumber: | 4057523963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 22101 | OK | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208M00000X | 22101 | OK | N | Allopathic & Osteopathic Physicians | Hospitalist | 2084N0400X | MD470175 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 200027210A | 05 | OK | MEDICAID |