Provider Demographics
NPI:1265469084
Name:WACH, MICHAEL LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LYNN
Last Name:WACH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 E FLORENCE AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5848
Mailing Address - Country:US
Mailing Address - Phone:323-749-6950
Mailing Address - Fax:323-749-6951
Practice Address - Street 1:3100 E FLORENCE AVE STE 4
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5848
Practice Address - Country:US
Practice Address - Phone:323-749-6950
Practice Address - Fax:323-749-6951
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4125213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41250Medicaid
CAE4125Medicare ID - Type Unspecified
CAU73184Medicare UPIN
1318450002Medicare NSC