Provider Demographics
NPI:1750360889
Name:MOATS, MICHAEL WILLIAM (MD,)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MOATS
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 1:2285 CORPORATE CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:525 E PLAZA DR
Practice Address - Street 2:SUITE #200
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6953
Practice Address - Country:US
Practice Address - Phone:805-922-3632
Practice Address - Fax:805-922-3522
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30085207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G300850Medicaid
CA00G300850OtherBLUE SHIELD OF CALIFORNIA
CAA44281Medicare UPIN
P00339526Medicare PIN
WG30085BMedicare PIN