Provider Demographics
NPI:1881605046
Name:YANUCK, MICHAEL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:YANUCK
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 1:107 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERLAIN
Mailing Address - State:SD
Mailing Address - Zip Code:57325-1741
Mailing Address - Country:US
Mailing Address - Phone:731-336-8465
Mailing Address - Fax:
Practice Address - Street 1:601 GALL STREET
Practice Address - Street 2:LOWER BRULE IHS HEALTH CENTER
Practice Address - City:LOWER BRULE
Practice Address - State:SD
Practice Address - Zip Code:57548
Practice Address - Country:US
Practice Address - Phone:605-473-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37538207R00000X
CAA75468207R00000X
IL036-114008207R00000X
OR25296207R00000X
DCMD037534207R00000X
CT047025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4120935Medicaid
3889172Medicare ID - Type Unspecified
TN4120935Medicaid