Provider Demographics
NPI:1912438250
Name:STALEY, MICHAELA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:STALEY
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 1:3177 OCEAN VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-1432
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:
Practice Address - Street 1:3177 OCEAN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-1432
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine