Provider Demographics
NPI:1235215302
Name:MCCORMICK, MICHAEL JUDE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUDE
Last Name:MCCORMICK
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 1:300 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE 235
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5082
Mailing Address - Country:US
Mailing Address - Phone:530-273-6530
Mailing Address - Fax:530-273-3951
Practice Address - Street 1:300 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 235
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5082
Practice Address - Country:US
Practice Address - Phone:530-273-6530
Practice Address - Fax:530-273-3951
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068844207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100570Medicaid
CAGR0100571Medicaid
CAGR0100571Medicaid
CAZZZ32015ZMedicare PIN
CAH41654Medicare UPIN