Provider Demographics
NPI:1629099080
Name:EBY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EBY
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 1:74785 US HIGHWAY 111
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-7128
Mailing Address - Country:US
Mailing Address - Phone:760-345-3932
Mailing Address - Fax:
Practice Address - Street 1:74785 US HIGHWAY 111
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-7128
Practice Address - Country:US
Practice Address - Phone:760-345-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70664207VC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A706640Medicaid
H68303Medicare UPIN
00A706641Medicare ID - Type Unspecified