1720028863 NPI number — DR. JEFFREY L MIKUTIS DO

Table of content: DR. JEFFREY L MIKUTIS DO (NPI 1720028863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720028863 NPI number — DR. JEFFREY L MIKUTIS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKUTIS
Provider First Name:
JEFFREY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1720028863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CHILDRENS PLZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45404-1815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-641-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45404-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-641-4000
Provider Business Practice Location Address Fax Number:
937-641-4500
Provider Enumeration Date:
06/07/2006

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: 207XP3100X , with the licence number:  34.005638 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05279 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 200533320 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0917664 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 326196 . This is a "ONE NATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 64117427 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0917664 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 200567 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4329917 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311676182027 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 326196 . This is a "BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 738694 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 278476 . This is a "AMERIGROUP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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