Provider Demographics
NPI:1629048178
Name:MIKUZIS, JOHN D (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MIKUZIS
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 1:850 BROOK FOREST AVE
Mailing Address - Street 2:UNIT F
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8513
Mailing Address - Country:US
Mailing Address - Phone:815-725-4918
Mailing Address - Fax:815-725-4955
Practice Address - Street 1:850 BROOK FOREST AVE
Practice Address - Street 2:UNIT F
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8513
Practice Address - Country:US
Practice Address - Phone:815-725-4918
Practice Address - Fax:815-725-4955
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077741208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4521533OtherBC/BS
IL158372300OtherDEPT OF LABOR
IL036077741Medicaid
IL4521533OtherBC/BS
ILL72932Medicare PIN
IL250010767Medicare PIN