Provider Demographics
NPI:1861486425
Name:MICHAELIS, KYLE JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JERRY
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:466 PEACOCK WAY
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-8783
Mailing Address - Country:US
Mailing Address - Phone:707-631-8476
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-5011
Practice Address - Fax:707-423-7496
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93950207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease