Provider Demographics
NPI:1225076458
Name:MICKUNAS, GREGORY J (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:MICKUNAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5201
Mailing Address - Fax:740-446-5761
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5201
Practice Address - Fax:740-446-5761
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21326207P00000X
OHH09359207P00000X
OH35.076915207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2183131Medicaid
930106929OtherRR MEDICARE
OH000000185284OtherUNISON MEDICAID #
001714125OtherMOUNTAIN STATE BCBS
000000205913OtherANTHEM BCBS
WV3002989000Medicaid
OH310917085143OtherOHIO MEDICAID CARESOURCE
H09359Medicare UPIN
WV3002989000Medicaid