Provider Demographics
NPI:1013040542
Name:MIKULA, MONIQUE RENE' (OD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:RENE'
Last Name:MIKULA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:RENE'
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3545 W 12TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2545
Mailing Address - Country:US
Mailing Address - Phone:970-356-9743
Mailing Address - Fax:970-352-4278
Practice Address - Street 1:3545 W 12TH ST
Practice Address - Street 2:STE 101
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2545
Practice Address - Country:US
Practice Address - Phone:970-356-9743
Practice Address - Fax:970-352-4278
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1684152W00000X, 152WC0802X, 152WP0200X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU66214Medicare UPIN
CO43813Medicare ID - Type Unspecified