Healthcare Provider Details

I. General information

NPI: 1093274342
Provider Name (Legal Business Name): MICHAEL JOSEPH CHISAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-2339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2020-03385
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: