Provider Demographics
NPI:1689456477
Name:NEEDHAM, MICHAEL GRANT
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRANT
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6331
Mailing Address - Country:US
Mailing Address - Phone:877-960-3426
Mailing Address - Fax:
Practice Address - Street 1:400 E OAK AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5034
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine