Provider Demographics
NPI:1598834244
Name:VENEZIANO, MICHELLE F (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:F
Last Name:VENEZIANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 4TH ST STE 227
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2699
Mailing Address - Country:US
Mailing Address - Phone:415-259-9026
Mailing Address - Fax:415-457-4837
Practice Address - Street 1:655 REDWOOD HWY FRONTAGE RD
Practice Address - Street 2:SUITE 160
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3034
Practice Address - Country:US
Practice Address - Phone:415-259-9026
Practice Address - Fax:415-457-4837
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X, 172M00000X, 174400000X, 174H00000X, 225700000X
CA20A8595204D00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA445248Medicaid
CAH49531Medicare UPIN