Provider Demographics
NPI:1356373138
Name:MICHELIN, MARITA JEAN (MD)
Entity type:Individual
Prefix:
First Name:MARITA
Middle Name:JEAN
Last Name:MICHELIN
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:700 SCOTT AND WHITE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-5600
Practice Address - Country:US
Practice Address - Phone:979-207-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT38945207P00000X
TXP7955207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G86023Medicare UPIN