Basic Information
| Provider Information | |||||||||
| NPI: | 1457596074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKUS | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MIKUS | ||||||||
| OtherFirstName: | RAYMOND | ||||||||
| OtherMiddleName: | BERNARD | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2404 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | HOLIDAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279450100 | ||||||||
| FaxNumber: | 7279450133 | ||||||||
| Practice Location | |||||||||
| Address1: | 2404 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | HOLIDAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346913943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279450100 | ||||||||
| FaxNumber: | 7279450133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2008 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS 10840 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.