Provider Demographics
NPI:1689635328
Name:DUFFY, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:DUFFY
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 1:99 N LA CIENEGA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2222
Mailing Address - Country:US
Mailing Address - Phone:310-623-1146
Mailing Address - Fax:310-623-1142
Practice Address - Street 1:9400 BRIGHTON WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4714
Practice Address - Country:US
Practice Address - Phone:310-271-6229
Practice Address - Fax:310-271-9139
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G595992Medicaid
CAWG59599AMedicare ID - Type Unspecified
CA00G595992Medicaid