Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 149352 | CA |
N | 111NI0900X | Internist | 149352 | CA |
Y | 207R00000X | Internist | 276683 | MA |
Y | 111NI0900X | Internist | 276683 | MA |
N | 207R00000X | Internist | 463951 | PA |
N | 111NI0900X | Internist | 463951 | PA |
N | 207RH0002X | Hospice and Palliative Medicine | 16379 | RI |
NPI | 1346669512 |
---|---|
Provider Name | Dr. Brian Mikolasko |
First Address | Boston, MA 02115-6110 |
Second Address | Boston, MA 02115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2014 |
Last Update Date | 07/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A149352 | THE MEDICAL BOARD OF CALIFORNIA (01) | CA |
FM6113461 | DEA (01) | |
MD463951 | PENNSYLVANIA STATE BOARD OF MEDICINE (01) | PA |