Provider Demographics
NPI:1407210453
Name:MAISON-FOMOTAR, MICHELE MEIME (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MEIME
Last Name:MAISON-FOMOTAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:MAISON MEIME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2335 E KASHIAN LN STE 280
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2211
Practice Address - Country:US
Practice Address - Phone:559-320-1090
Practice Address - Fax:559-320-0331
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160693207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine