Provider Demographics
NPI:1720028863
Name:MIKUTIS, JEFFREY L (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:MIKUTIS
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 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1815
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-4500
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.005638207XP3100X
OH34005638M207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH05279OtherPARAMOUNT
IN200533320Medicaid
OH0917664Medicaid
OH326196OtherONE NATION
KY64117427Medicaid
OH0917664OtherBCMH
OH200567OtherUNISON
OH4329917OtherAETNA
OH311676182027OtherCARESOURCE
OH326196OtherBC/BS
OH738694OtherBUCKEYE
OH278476OtherAMERIGROUP
OH4329917OtherAETNA
OH0917664Medicaid