Provider Demographics
NPI:1932216785
Name:MIKO, THEODORE (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:MIKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4391 FALLOWFIELD LN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7405
Mailing Address - Country:US
Mailing Address - Phone:678-380-4081
Mailing Address - Fax:678-380-4348
Practice Address - Street 1:4391 FALLOWFIELD LN SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-7405
Practice Address - Country:US
Practice Address - Phone:678-380-4081
Practice Address - Fax:678-380-4348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044966174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist