Provider Demographics
NPI:1174671036
Name:JIU, MICHELE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:JIU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:ANNE
Other - Last Name:FREI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4425 PROMESA CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2313
Mailing Address - Country:US
Mailing Address - Phone:858-336-1376
Mailing Address - Fax:
Practice Address - Street 1:4425 PROMESA CIR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2313
Practice Address - Country:US
Practice Address - Phone:858-336-1376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH04513Medicare UPIN