Provider Demographics
NPI:1982667697
Name:MIKO, SUSAN A (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:MIKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 MARBELLA RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1488
Mailing Address - Country:US
Mailing Address - Phone:702-254-2720
Mailing Address - Fax:
Practice Address - Street 1:657 N TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6367
Practice Address - Country:US
Practice Address - Phone:702-233-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1212207P00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505930Medicaid
AZAZ0201750OtherAZ BC/BS
AZ020537Medicaid
NVBK083BMedicare PIN
NVCM138YMedicare UPIN
AZ020537Medicaid
NVBK083AMedicare PIN
AZHSZ134Medicare PIN
AZAZ0201750OtherAZ BC/BS
AZ031307Medicare Oscar/Certification