Provider Demographics
NPI:1659351203
Name:MAINE, MICHAEL CRAIG JR (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:MAINE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8404
Mailing Address - Country:US
Mailing Address - Phone:619-528-5000
Mailing Address - Fax:
Practice Address - Street 1:4650 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-8404
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203388207Q00000X
PAOS011223207Q00000X
CA20A8559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H48226Medicare UPIN
050773Medicare ID - Type Unspecified