Provider Demographics
NPI:1962510727
Name:MIKULSKI, WANDA JANINA (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:JANINA
Last Name:MIKULSKI
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 1:1310 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-338-5660
Mailing Address - Fax:973-338-0522
Practice Address - Street 1:1310 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-338-5660
Practice Address - Fax:973-338-0522
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMA035627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1097806Medicaid
NJ1097806Medicaid
C52733Medicare UPIN