Provider Demographics
NPI:1861495020
Name:HEALY, MICHAEL DYLAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DYLAN
Last Name:HEALY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:323 N PRAIRIE AVE
Mailing Address - Street 2:STE 334
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4505
Mailing Address - Country:US
Mailing Address - Phone:310-674-8600
Mailing Address - Fax:310-671-9883
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:STE 334
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4505
Practice Address - Country:US
Practice Address - Phone:310-674-8600
Practice Address - Fax:310-671-9883
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG27842207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G278420Medicaid
CAA91089Medicare UPIN
CAWG27842AMedicare ID - Type Unspecified
CAWG27842BMedicare ID - Type Unspecified