Provider Demographics
NPI:1720122450
Name:MICHAELS, KEITH P (AUD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:P
Last Name:MICHAELS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6229 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3901
Mailing Address - Country:US
Mailing Address - Phone:310-677-1168
Mailing Address - Fax:310-677-0203
Practice Address - Street 1:6229 W 87TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3901
Practice Address - Country:US
Practice Address - Phone:310-677-1168
Practice Address - Fax:310-677-0203
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2428237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU2428OtherAUDIOLOGY LICENSE NUMBER
CAGAU001090Medicaid
CAAU0024280Medicaid
CAHA7011OtherHEARING AID DISPENSER NUM
CAZZZ62880ZOtherBLUE SHIELD
CAZZZ62880ZOtherBLUE SHIELD