Provider Demographics
NPI:1023097938
Name:MIKUS, KEVIN P (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:MIKUS
Suffix:
Gender:M
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 601952
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1952
Mailing Address - Country:US
Mailing Address - Phone:704-302-8375
Mailing Address - Fax:704-302-8548
Practice Address - Street 1:4525 CAMERON VALLEY PKWY STE 3100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4377
Practice Address - Country:US
Practice Address - Phone:704-302-8375
Practice Address - Fax:704-302-9071
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27952173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCN8132OtherMEDICARE RAILROAD
NC8958796Medicaid
NCCN8132OtherMEDICARE RAILROAD
NC208856BMedicare ID - Type Unspecified
NC208856DMedicare PIN
NC208856CMedicare PIN