Provider Demographics
NPI:1225048648
Name:VISICK, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:VISICK
Suffix:
Gender:M
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-716-1940
Mailing Address - Fax:
Practice Address - Street 1:506 LAKE ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-6937
Practice Address - Country:US
Practice Address - Phone:907-714-4111
Practice Address - Fax:844-412-3952
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4739087-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH20280Medicare UPIN
UT000064012Medicare PIN