Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | G31552 | CA |
NPI | 1225027709 |
---|---|
Provider Name | Dr. Michael David Fox |
First Address | Mill Valley, CA 94941-1339 |
Second Address | Mill Valley, CA 94941-1339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2005 |
Last Update Date | 21/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G315520 | (05) | CA |
00G315520 | BLUE SHIELD (01) | CA |
A44808 | (02) |