Provider Demographics
NPI:1346293248
Name:MIKRUT, JAMES (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MIKRUT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13175 E HIGHWAY 169
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-7372
Mailing Address - Country:US
Mailing Address - Phone:928-632-0800
Mailing Address - Fax:928-632-8505
Practice Address - Street 1:13175 E HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-7372
Practice Address - Country:US
Practice Address - Phone:928-632-0800
Practice Address - Fax:928-632-8505
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6486225100000X
MI5501005426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ915936Medicaid
Z101584Medicare PIN
AZQ37751Medicare UPIN