Basic Information
| Provider Information | |||||||||
| NPI: | 1205173762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKHAIL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 BINGHAM AVENUE, SUITE B | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325751100 | ||||||||
| FaxNumber: | 7325751107 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 BINGHAM AVENUE, SUITE B | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325751100 | ||||||||
| FaxNumber: | 7325751107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2013 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RP1001X | 25MA09268500 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0448591 | 05 | NJ | MEDICAID |