Provider Demographics
NPI:1205893104
Name:HURST, MICHAEL D (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:HURST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 W 11TH ST
Mailing Address - Street 2:SUITE 119
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3856
Mailing Address - Country:US
Mailing Address - Phone:209-832-5500
Mailing Address - Fax:209-832-5505
Practice Address - Street 1:632 W 11TH ST
Practice Address - Street 2:SUITE 119
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3856
Practice Address - Country:US
Practice Address - Phone:209-832-5500
Practice Address - Fax:209-832-5505
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8081207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX80810Medicaid
CA00AX80810Medicaid
CA020A80810Medicare PIN