Provider Demographics
NPI:1629277322
Name:DE MIK, TRAVIS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:JAMES
Last Name:DE MIK
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 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-269-0674
Practice Address - Street 1:8505 ARLINGTON BLVD STE 410
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4636
Practice Address - Country:US
Practice Address - Phone:703-560-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA108228207V00000X
VA0101250347207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty