Provider Demographics
NPI:1063615797
Name:MICHAUD, ROBERT JEROME
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEROME
Last Name:MICHAUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:JEROME
Other - Last Name:MICHAUD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1270 N MARINE DR STE 101
Mailing Address - Street 2:PMB 537
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4331
Mailing Address - Country:US
Mailing Address - Phone:619-512-3406
Mailing Address - Fax:
Practice Address - Street 1:1270 N MARINE DR STE 101
Practice Address - Street 2:PMB 537
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-4331
Practice Address - Country:US
Practice Address - Phone:619-512-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1232207P00000X
TXP7512207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine