1134128788 NPI number — ILIANA DOMENICA MICALI M.D.

Table of content: ILIANA DOMENICA MICALI M.D. (NPI 1134128788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134128788 NPI number — ILIANA DOMENICA MICALI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICALI
Provider First Name:
ILIANA
Provider Middle Name:
DOMENICA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134128788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 2ND ST SE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98002-5543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-333-8646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 2ND ST SE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-5543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-333-8646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD00037682 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 912006268 MI8274 . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 912006268 98002 0000 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0171332 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2225134 . This is a "AETNA HEALTH MANAGEMENT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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