Provider Demographics
NPI:1114059185
Name:MIKLOUCICH, JEROME JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JOSEPH
Last Name:MIKLOUCICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276-280 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1659
Mailing Address - Country:US
Mailing Address - Phone:607-722-2769
Mailing Address - Fax:
Practice Address - Street 1:276-280 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1659
Practice Address - Country:US
Practice Address - Phone:607-722-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03113559Medicaid
NYJ400003363Medicare PIN