Provider Demographics
NPI:1821036195
Name:MIKIELSKI, KEVIN JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:MIKIELSKI
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 1:4002 SCHAPER AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508
Mailing Address - Country:US
Mailing Address - Phone:814-866-2311
Mailing Address - Fax:814-860-8111
Practice Address - Street 1:4002 SCHAPER AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508
Practice Address - Country:US
Practice Address - Phone:814-866-2311
Practice Address - Fax:814-860-8111
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012785207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016482560001Medicaid
PA1016482560001Medicaid
PAI55875Medicare UPIN