Provider Demographics
NPI:1194733063
Name:MAYNARD, MICHELLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:DODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3752
Practice Address - Country:US
Practice Address - Phone:916-536-2500
Practice Address - Fax:916-780-3904
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87053207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD44226Medicare UPIN
CAWG7053AMedicare PIN