Provider Demographics
NPI:1760461305
Name:MIKILITUS, RICHARD JOHN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:MIKILITUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:524 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3805
Mailing Address - Country:US
Mailing Address - Phone:770-832-2775
Mailing Address - Fax:770-832-9529
Practice Address - Street 1:524 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3805
Practice Address - Country:US
Practice Address - Phone:770-832-2775
Practice Address - Fax:770-832-9529
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0401592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5632868OtherCIGNA
GA5997084OtherAETNA HEALTH CARE
GA000670909AMedicaid
130011906OtherR X R MEDICARE
GA000670909FMedicaid
1281548OtherUNITED HEALTHCARE
AL009602420Medicaid
506390OtherBCBS
GA000670909EMedicaid
GA000670909EMedicaid
506390OtherBCBS
1281548OtherUNITED HEALTHCARE
GA000670909FMedicaid