Basic Information
| Provider Information | |||||||||
| NPI: | 1043233737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHELSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11175 CAMPUS ST | ||||||||
| Address2: | CP A1120F | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923501700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588242 | ||||||||
| FaxNumber: | 9095580479 | ||||||||
| Practice Location | |||||||||
| Address1: | 2195 CLUB CENTER DR | ||||||||
| Address2: | STE A | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924084170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098351810 | ||||||||
| FaxNumber: | 9098351780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | A72008 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2084N0402X | A72008 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.