Provider Demographics
NPI:1063412104
Name:MICHAEL, DWIGHT IRA (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:IRA
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-5122
Mailing Address - Country:US
Mailing Address - Phone:717-766-1795
Mailing Address - Fax:717-697-6575
Practice Address - Street 1:2140 FISHER RD
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-5122
Practice Address - Country:US
Practice Address - Phone:717-766-1795
Practice Address - Fax:717-697-6575
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-029636E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012418 02Medicaid
PA159809J9CMedicare ID - Type Unspecified
C32298Medicare UPIN