Provider Demographics
NPI:1548339229
Name:MIKESH, MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MIKESH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 STONELEIGH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3940
Mailing Address - Country:US
Mailing Address - Phone:845-278-8400
Mailing Address - Fax:845-278-4326
Practice Address - Street 1:2 VICTORY CT
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-1745
Practice Address - Country:US
Practice Address - Phone:845-565-1454
Practice Address - Fax:845-565-9803
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020332-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01572430Medicaid
NYQ5611CJ511OtherPTAN
NYQK6111Medicare ID - Type Unspecified