Provider Demographics
NPI:1285896407
Name:YUAN, MIKE (MD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:YUAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15005 SHADY GROVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6341
Mailing Address - Country:US
Mailing Address - Phone:240-660-2798
Mailing Address - Fax:301-576-3698
Practice Address - Street 1:15825 SHADY GROVE RD STE 130
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4031
Practice Address - Country:US
Practice Address - Phone:240-660-2786
Practice Address - Fax:240-516-7056
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248968208100000X
PAMD4430502081S0010X
MDD00742282081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC243224OtherMEDICARE PTAN
MD243456OtherMEDICARE PTAN