Provider Demographics
NPI:1255366050
Name:MIKACICH, JUDITH ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ANN
Last Name:MIKACICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 FAIR OAKS BLVD
Mailing Address - Street 2:SUITE 355
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-5533
Mailing Address - Country:US
Mailing Address - Phone:916-927-3178
Mailing Address - Fax:916-927-1488
Practice Address - Street 1:2277 FAIR OAKS BLVD
Practice Address - Street 2:SUITE 355
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-5533
Practice Address - Country:US
Practice Address - Phone:916-927-3178
Practice Address - Fax:916-927-1488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73791207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A737910OtherMEDICAL
CAH85555Medicare UPIN
CAWA73791AMedicare ID - Type Unspecified