Provider Demographics
NPI:1477538130
Name:SERRA, MICHAEL JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SERRA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5313
Mailing Address - Country:US
Mailing Address - Phone:831-375-1885
Mailing Address - Fax:831-375-7436
Practice Address - Street 1:5910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-475-1000
Practice Address - Fax:209-475-1809
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT152172Medicare PIN