Healthcare Provider Details

I. General information

NPI: 1518572510
Provider Name (Legal Business Name): MICHAEL D PRENTICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MINERAL KING AVE
VISALIA CA
93291-6237
US

IV. Provider business mailing address

9975 MERLIN DR E
JACKSONVILLE FL
32257-5827
US

V. Phone/Fax

Practice location:
  • Phone: 949-355-5115
  • Fax:
Mailing address:
  • Phone: 949-355-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1518572510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: