Provider Demographics
NPI:1366434912
Name:SOMPLE, MICHAEL JAY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:SOMPLE
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 1:751 FOREST AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2868
Mailing Address - Country:US
Mailing Address - Phone:740-452-4053
Mailing Address - Fax:740-452-4580
Practice Address - Street 1:751 FOREST AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2868
Practice Address - Country:US
Practice Address - Phone:740-452-4053
Practice Address - Fax:740-452-4580
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046011S2084N0400X
OH350460112085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000122287OtherANTHEM PROVIDER NUMBER
OH0469738Medicaid
OH311597742OtherTAX ID
OH000000122287OtherANTHEM PROVIDER NUMBER
OH0469738Medicaid
OHA80007Medicare UPIN
OHSO0495489Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER