Provider Demographics
NPI:1548345390
Name:KAUK, MITCHELL (PT OCS)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:KAUK
Suffix:
Gender:M
Credentials:PT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224A WELLER ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3136
Mailing Address - Country:US
Mailing Address - Phone:707-762-7678
Mailing Address - Fax:707-762-7679
Practice Address - Street 1:224A WELLER ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3136
Practice Address - Country:US
Practice Address - Phone:707-762-7678
Practice Address - Fax:707-762-7679
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT109592251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA093769OtherHEALTHNET PROVIDER ID
CA677476OtherACN/BLUE SHIELD PROVIDER
CAPT0109590Medicaid
CAPT0109590Medicaid