Provider Demographics
NPI:1912908435
Name:MICH, JEFFREY LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:MICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 117TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2666
Mailing Address - Country:US
Mailing Address - Phone:763-421-7300
Mailing Address - Fax:763-421-3337
Practice Address - Street 1:3790 117TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2666
Practice Address - Country:US
Practice Address - Phone:763-421-7300
Practice Address - Fax:763-421-3337
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN620213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33942OtherHEALTH PARTNERS
MN27D36MIOtherBLUE CROSS BLUE SHIELD
MN867912600Medicaid
MN2700167OtherMEDICA
MN140086OtherUCARE
MN33942OtherHEALTH PARTNERS
MNU81865Medicare UPIN
MN480000374Medicare ID - Type Unspecified