Provider Demographics
NPI:1194885871
Name:INDIANER, MICHELLE (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:INDIANER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 BLOSSOM HILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-4420
Mailing Address - Country:US
Mailing Address - Phone:408-395-4117
Mailing Address - Fax:408-395-1441
Practice Address - Street 1:250 BLOSSOM HILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-4420
Practice Address - Country:US
Practice Address - Phone:408-395-4117
Practice Address - Fax:408-395-1441
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A46212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE24901Medicare UPIN