Provider Demographics
NPI:1134128788
Name:MICALI, ILIANA DOMENICA (MD)
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:DOMENICA
Last Name:MICALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 2ND ST SE
Mailing Address - Street 2:STE 100
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5543
Mailing Address - Country:US
Mailing Address - Phone:253-333-8646
Mailing Address - Fax:
Practice Address - Street 1:309 2ND ST SE
Practice Address - Street 2:STE 100
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5543
Practice Address - Country:US
Practice Address - Phone:253-333-8646
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912006268 MI8274OtherREGENCE BLUESHIELD
WA912006268 98002 0000OtherTRICARE
WA0171332OtherLABOR & INDUSTRIES
WA2225134OtherAETNA HEALTH MANAGEMENT
WA0171332OtherLABOR & INDUSTRIES
WA912006268 98002 0000OtherTRICARE