Provider Demographics
NPI:1821033861
Name:TEKAUTZ, MICHAEL RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RUSSELL
Last Name:TEKAUTZ
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG427302085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G427300Medicaid
CA00G4273013Medicare PIN
CA300024674Medicare PIN
CA00G427305Medicare PIN
CA00G4273015Medicare PIN
CA00G427301Medicare PIN
CA00G427303Medicare PIN
CA00G427309Medicare PIN
CA00G4273010Medicare PIN
CA00G4273012Medicare PIN
CA00G427300Medicaid
CA00G4273011Medicare PIN
CA00G4273014Medicare PIN
CA00G427302Medicare PIN
CA00G427307Medicare PIN
CA00G427308Medicare PIN
CA00G427304Medicare PIN
CA00G427300Medicare PIN
CA00G427306Medicare PIN