Provider Demographics
NPI:1437129574
Name:MIKULSKI, ADAM MARK (DO)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:MARK
Last Name:MIKULSKI
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 1:1404 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4668
Mailing Address - Country:US
Mailing Address - Phone:215-364-1500
Mailing Address - Fax:215-364-5140
Practice Address - Street 1:1404 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4668
Practice Address - Country:US
Practice Address - Phone:215-364-1500
Practice Address - Fax:215-364-5140
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010539L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
063583TQNMedicare ID - Type Unspecified
PAH72417Medicare UPIN