Provider Demographics
NPI:1346670007
Name:FINE, MICHAEL JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:FINE
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 1:736 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-4110
Mailing Address - Country:US
Mailing Address - Phone:949-499-4736
Mailing Address - Fax:
Practice Address - Street 1:736 KENDALL DR
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-4110
Practice Address - Country:US
Practice Address - Phone:949-499-4736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-16
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43133302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization