Provider Demographics
NPI:1750487542
Name:JUSTIN P. MIKULA, M.D., INC.
Entity Type:Organization
Organization Name:JUSTIN P. MIKULA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MIKULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-372-2333
Mailing Address - Street 1:1615 N RIVER RD NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-2437
Mailing Address - Country:US
Mailing Address - Phone:330-372-2333
Mailing Address - Fax:330-373-1111
Practice Address - Street 1:1615 N RIVER RD NE
Practice Address - Street 2:SUITE 1
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-2437
Practice Address - Country:US
Practice Address - Phone:330-372-2333
Practice Address - Fax:330-373-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9357811Medicare ID - Type UnspecifiedGROUP NUMBER