Provider Demographics
NPI:1255591772
Name:MIKLOUCICH, CORI LEE (DO)
Entity type:Individual
Prefix:DR
First Name:CORI
Middle Name:LEE
Last Name:MIKLOUCICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:CORI
Other - Middle Name:LEE
Other - Last Name:SOCHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1130 UPPER FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1118
Mailing Address - Country:US
Mailing Address - Phone:607-772-1995
Mailing Address - Fax:
Practice Address - Street 1:1130 UPPER FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1118
Practice Address - Country:US
Practice Address - Phone:607-772-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03024531Medicaid
NY03024531Medicaid