Provider Demographics
NPI:1609965797
Name:EBAUGH, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:EBAUGH
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 1:254 N KESSING ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3424
Mailing Address - Country:US
Mailing Address - Phone:559-781-8500
Mailing Address - Fax:559-781-8300
Practice Address - Street 1:254 N KESSING ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3424
Practice Address - Country:US
Practice Address - Phone:559-781-8500
Practice Address - Fax:559-781-8300
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06893ZOtherBLUE SHIELD
CAGR0099940Medicaid
CAZZZ24124ZMedicare ID - Type Unspecified