Provider Demographics
NPI:1497853154
Name:MIKLOS, RUSSELL DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DAVID
Last Name:MIKLOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:DAVID
Other - Last Name:MIKLOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 413
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-0413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4550 LIBERTY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-1910
Practice Address - Country:US
Practice Address - Phone:440-967-5545
Practice Address - Fax:440-967-5546
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4128771Medicare PIN
U99172Medicare UPIN