=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831536564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE TO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2013
-----------------------------------------------------
Last Update Date | 04/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11301 WILSHIRE BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90073-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-268-3747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11301 WILSHIRE BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90073-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-268-3747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0015X
-----------------------------------------------------
Taxonomy Name | Psychosomatic Medicine Physician
-----------------------------------------------------
License Number | 278279
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0015X
-----------------------------------------------------
Taxonomy Name | Psychosomatic Medicine Physician
-----------------------------------------------------
License Number | A158718
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------