Provider Demographics
NPI:1164436820
Name:LIN, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:LIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:TING-SHUNG
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:28049 SMYTH DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-4023
Mailing Address - Country:US
Mailing Address - Phone:818-906-6900
Mailing Address - Fax:818-906-6903
Practice Address - Street 1:15477 VENTURA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3006
Practice Address - Country:US
Practice Address - Phone:818-906-6900
Practice Address - Fax:818-906-6903
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77571207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A775711Medicaid
A77571Medicare UPIN
CA00A775711Medicaid