Provider Demographics
NPI:1962401463
Name:ZELK, MISTY MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MICHELLE
Last Name:ZELK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PETALUMA AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4281
Mailing Address - Country:US
Mailing Address - Phone:707-823-7616
Mailing Address - Fax:
Practice Address - Street 1:652 PETALUMA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4256
Practice Address - Country:US
Practice Address - Phone:707-823-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1505207R00000X, 208000000X
CAC54385207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140545001Medicaid
ARH19740Medicare UPIN