Healthcare Provider Details

I. General information

NPI: 1972422566
Provider Name (Legal Business Name): JOHN JOSEPH MICHELITCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6729
US

IV. Provider business mailing address

1401 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6729
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1703
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: