Provider Demographics
NPI:1942347190
Name:MIKHAILOVA, VERA (MD)
Entity Type:Individual
Prefix:DR
First Name:VERA
Middle Name:
Last Name:MIKHAILOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1100 W 10TH ST
Practice Address - Street 2:SUITE 175
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2937
Practice Address - Country:US
Practice Address - Phone:573-341-9163
Practice Address - Fax:573-368-4248
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027391208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208413708Medicaid
MO208413708Medicaid
MO918193230Medicare PIN