Provider Demographics
NPI:1316124894
Name:HANOWELL, MICHAEL DALTON (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALTON
Last Name:HANOWELL
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:5126 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2566
Practice Address - Country:US
Practice Address - Phone:770-385-4426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-27
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001560207L00000X
GA061846208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I946122Medicare PIN
GAP01680677Medicare PIN
GA202I091821Medicare PIN
GA202I720101Medicare PIN
FLP00909958Medicare PIN