Provider Demographics
NPI:1679849111
Name:MICHAEL, JESSIKA DIAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSIKA
Middle Name:DIAZ
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSIKA
Other - Middle Name:
Other - Last Name:DIAZ LARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:4 TOWER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:714-749-0907
Mailing Address - Fax:
Practice Address - Street 1:202 S PARK ST
Practice Address - Street 2:UNITY POINT MERITER 4 TOWER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1507
Practice Address - Country:US
Practice Address - Phone:608-417-6676
Practice Address - Fax:608-417-5746
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA135774207L00000X
WI70495207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology