Provider Demographics
NPI:1104826890
Name:MIKOS, DAVID (DC, PT, MCTA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MIKOS
Suffix:
Gender:M
Credentials:DC, PT, MCTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2207
Mailing Address - Country:US
Mailing Address - Phone:203-239-4274
Mailing Address - Fax:203-239-4290
Practice Address - Street 1:202 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2207
Practice Address - Country:US
Practice Address - Phone:203-239-4274
Practice Address - Fax:203-239-4290
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004290225100000X
CT001238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008050328 (CHIRO)Medicaid
CT004168086 (PT)Medicaid
CTD400000773 (CHIRO)Medicare PIN
CT004168086 (PT)Medicaid