Provider Demographics
NPI:1346668878
Name:MIKULIC, ANNA CHRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:CHRISTINE
Last Name:MIKULIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:CHRISTINE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:503-941-3033
Mailing Address - Fax:503-747-7013
Practice Address - Street 1:10690 NE CORNELL RD STE 220
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9224
Practice Address - Country:US
Practice Address - Phone:503-848-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD192549207Q00000X
MT59870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500672939Medicaid