Provider Demographics
NPI:1255368395
Name:MIKOLAJCZAK, DAVID J (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MIKOLAJCZAK
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 1:18021 SOUTH HUNT CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER CROSS BLVD
Practice Address - Street 2:SILVER CROSS HOSPITAL
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9509
Practice Address - Country:US
Practice Address - Phone:815-740-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073719207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILO36073719Medicaid
ILC40474Medicare UPIN
ILO36073719Medicaid