Provider Demographics
NPI:1194152389
Name:CHRISTOPHER, MICHAEL RAY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:CHRISTOPHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 S VINE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-520-3905
Mailing Address - Fax:903-535-9304
Practice Address - Street 1:1306 S VINE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2822
Practice Address - Country:US
Practice Address - Phone:903-520-3905
Practice Address - Fax:903-535-9304
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1224803172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1224803Medicaid
TX1224803OtherLIFE AND HEALTH