Provider Demographics
NPI:1649246174
Name:MICHEL, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MICHEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012
Mailing Address - Country:US
Mailing Address - Phone:323-665-5600
Mailing Address - Fax:323-665-8500
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:#610
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-665-5600
Practice Address - Fax:323-665-8502
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE31042208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310420Medicaid
A31042Medicare ID - Type Unspecified
A84165Medicare UPIN