Basic Information
| Provider Information | |||||||||
| NPI: | 1134123920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHALIK | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1081 N CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N CHINA LAKE BLVD STE 190 | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G32768 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | G32768 | 01 | IMG | OTHER | 00G327680 | 01 | COMMERCIAL CARRIERS | OTHER | 00G327680 | 05 | CA | MEDICAID | 00G327680 | 01 | BLUE SHIELD | OTHER | 93555B034 | 01 | TRIWEST/TRICARE | OTHER | AM7317945 | 01 | DEA | OTHER | 00G327680 | 01 | BLUE CROSS | OTHER | CA0103 | 01 | JOHN DEERE | OTHER | 0616650001 | 01 | DME | OTHER |