Provider Demographics
NPI:1093826950
Name:MICHALIK, JAROSLAW
Entity Type:Individual
Prefix:
First Name:JAROSLAW
Middle Name:
Last Name:MICHALIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 MATTOX DR
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2365
Mailing Address - Country:US
Mailing Address - Phone:573-860-6000
Mailing Address - Fax:573-860-6016
Practice Address - Street 1:965 MATTOX DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2365
Practice Address - Country:US
Practice Address - Phone:573-860-6000
Practice Address - Fax:573-860-6016
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114756208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203776505Medicaid
MO203776505Medicaid
G78748Medicare UPIN