Healthcare Provider Details

I. General information

NPI: 1205893104
Provider Name (Legal Business Name): MICHAEL D HURST DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 W 11TH ST SUITE 119
TRACY CA
95376-3856
US

IV. Provider business mailing address

632 W 11TH ST SUITE 119
TRACY CA
95376-3856
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-5500
  • Fax: 209-832-5505
Mailing address:
  • Phone: 209-832-5500
  • Fax: 209-832-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A8081
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A8081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: