Healthcare Provider Details

I. General information

NPI: 1457308868
Provider Name (Legal Business Name): MIKE P FEALY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6412 LAUREL AVE MOUNTAIN MESA
LAKE ISABELLA CA
93240-9529
US

IV. Provider business mailing address

1140 ORCHID DR
SANTA BARBARA CA
93111-2913
US

V. Phone/Fax

Practice location:
  • Phone: 760-379-2681
  • Fax:
Mailing address:
  • Phone: 805-637-6932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG63961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: