Provider Demographics
NPI:1538321740
Name:MICHAELIS, MILTON SIEGFRIED (MD)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:SIEGFRIED
Last Name:MICHAELIS
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 1:57158 MEDINAH
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-6915
Mailing Address - Country:US
Mailing Address - Phone:760-777-9378
Mailing Address - Fax:
Practice Address - Street 1:2700 CLARE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3330
Practice Address - Country:US
Practice Address - Phone:360-479-6555
Practice Address - Fax:360-479-8321
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-29
Last Update Date:2008-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000112942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1816107Medicaid
AO6965Medicare UPIN
WA1816107Medicaid