Provider Demographics
NPI:1679525356
Name:MIKHAILOV, THERESA A (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:MIKHAILOV
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC CRITICAL CARE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-3360
Mailing Address - Fax:414-266-3563
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC CRITICAL CARE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3360
Practice Address - Fax:414-266-3563
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI409622080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679525356Medicaid
002000329DOtherHUMANA
WI092J73601Medicare PIN
F76063Medicare UPIN