1952680829 NPI number — DR. KAREN M MIKOLIC PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952680829 NPI number — DR. KAREN M MIKOLIC PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKOLIC
Provider First Name:
KAREN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1952680829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 721034
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92172-1034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-221-6311
Provider Business Mailing Address Fax Number:
888-388-2142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 LA JOLLA VILLAGE DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-4604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-221-6311
Provider Business Practice Location Address Fax Number:
888-388-2142
Provider Enumeration Date:
08/10/2011

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: 103T00000X , with the licence number:  PSY1000723 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X , with the licence number: PY8438 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N/A , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PY8438 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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