Provider Demographics
NPI:1700985413
Name:MIELKE, LYNNE R (MD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:R
Last Name:MIELKE
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 1:4463 STONERIDGE DR STE A
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8402
Mailing Address - Country:US
Mailing Address - Phone:925-846-6300
Mailing Address - Fax:925-846-6323
Practice Address - Street 1:4463 STONERIDGE DR STE A
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8402
Practice Address - Country:US
Practice Address - Phone:925-846-6300
Practice Address - Fax:925-846-6323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG590172084P0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF02058Medicare UPIN