Provider Demographics
NPI:1467448662
Name:MICHENER, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MICHENER
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 1:3841 PIPER ST STE T4-020
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4673
Mailing Address - Country:US
Mailing Address - Phone:907-646-8500
Mailing Address - Fax:
Practice Address - Street 1:3841 PIPER ST STE T4-020
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4673
Practice Address - Country:US
Practice Address - Phone:907-646-8500
Practice Address - Fax:907-646-9760
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114135207N00000X
IL036-114135207Q00000X
AK129488207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN