Provider Demographics
NPI:1326332701
Name:NOVALES, MICHELLE THERESE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESE
Last Name:NOVALES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:THERESE
Other - Last Name:NOVALES GOMOGDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4405 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4405 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3315
Practice Address - Country:US
Practice Address - Phone:619-516-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine