Provider Demographics
NPI:1134182348
Name:WILLETT, MICHAEL WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:WILLETT
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 1:155 DIGGLES STREET
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:CA
Mailing Address - Zip Code:96027
Mailing Address - Country:US
Mailing Address - Phone:530-467-5393
Mailing Address - Fax:
Practice Address - Street 1:155 DIGGLES STREET
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:CA
Practice Address - Zip Code:96027
Practice Address - Country:US
Practice Address - Phone:530-467-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G564810Medicaid
CA00G564810Medicaid
CAE25031Medicare UPIN