Provider Demographics
NPI:1750363230
Name:MIKOLAJCZAK, MICHAEL R (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:MIKOLAJCZAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10115 FOREST HILL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6178
Mailing Address - Country:US
Mailing Address - Phone:561-670-2010
Mailing Address - Fax:561-670-2319
Practice Address - Street 1:10115 FOREST HILL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6178
Practice Address - Country:US
Practice Address - Phone:561-670-2010
Practice Address - Fax:561-670-2319
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5531207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255341400Medicaid
FL255341400Medicaid
80090ZMedicare PIN