Provider Demographics
NPI:1417120866
Name:MEDEIROS, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MEDEIROS
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 1:4032 W SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERS
Mailing Address - State:CA
Mailing Address - Zip Code:93609-9552
Mailing Address - Country:US
Mailing Address - Phone:559-856-6170
Mailing Address - Fax:559-856-6172
Practice Address - Street 1:2256 DOCKERY AVE STE B
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3874
Practice Address - Country:US
Practice Address - Phone:559-856-6170
Practice Address - Fax:559-856-6172
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117400207R00000X
MN647252084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12583839OtherCAQH NUMBER
CAA117400OtherLICENSE NUMBER
NV18511OtherLICENSE NUMBER