Provider Demographics
NPI:1922091487
Name:ETNYRE AND MIKUNI MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ETNYRE AND MIKUNI MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-349-1202
Mailing Address - Street 1:301 S MILLER ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5205
Mailing Address - Country:US
Mailing Address - Phone:805-349-1202
Mailing Address - Fax:805-349-0974
Practice Address - Street 1:301 S MILLER ST
Practice Address - Street 2:SUITE 214
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5205
Practice Address - Country:US
Practice Address - Phone:805-349-1202
Practice Address - Fax:805-349-0974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG074101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14643Medicare PIN