1326024373 NPI number — MRS. KATHERINE DALTON MIKA M.D.

Table of content: LULA MOULTRIE HEATLEY LCSW-C (NPI 1164702098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326024373 NPI number — MRS. KATHERINE DALTON MIKA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKA
Provider First Name:
KATHERINE
Provider Middle Name:
DALTON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326024373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3067 DARBY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KESWICK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22947-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-984-8899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1522 INSURANCE LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22911-7229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-974-9600
Provider Business Practice Location Address Fax Number:
434-296-1036
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101040389 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 006725783 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010718 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 333852 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 20028 . This is a "VETRI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 267171 . This is a "MAMSI/ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 12062400003 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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