Basic Information
| Provider Information | |||||||||
| NPI: | 1629277322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE MIK | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192690674 | ||||||||
| Practice Location | |||||||||
| Address1: | 8505 ARLINGTON BLVD STE 410 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035609070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | A108228 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 0101250347 | VA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.