Provider Demographics
NPI:1740250323
Name:NUSSDORFER, MICHAEL CRAIG (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:NUSSDORFER
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 1:1700 S COURT ST STE F
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4931
Mailing Address - Country:US
Mailing Address - Phone:559-734-9244
Mailing Address - Fax:559-734-6932
Practice Address - Street 1:1700 S COURT ST STE F
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4931
Practice Address - Country:US
Practice Address - Phone:559-734-9244
Practice Address - Fax:559-734-6932
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV66202085R0202X
CAG739142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G739140Medicaid
NV002003018Medicaid
NV300127544OtherRAILROAD MEDICARE
CA300127546OtherRAILROAD MEDICARE
NV002003018Medicaid
CA00G739140Medicare PIN
CA300127546OtherRAILROAD MEDICARE