MEDICARE: MISTY MICHELLE ZELK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	E-1505	AR
2	208000000X	Pediatrics Physician	E-1505	AR
3	207R00000X	Internal Medicine Physician	C54385	CA
4	208000000X	Pediatrics Physician	C54385	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962401463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY MICHELLE ZELK M.D.

Provider Business Mailing Address
First Line	:	501 PETALUMA AVE
Second Line	:	SUITE H
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4281
Country	:	US
Telephone Number	:	707-823-7616
Fax Number	:

Provider Business Practice Location Address
First Line	:	652 PETALUMA AVE
Second Line	:	SUITE H
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4256
Country	:	US
Telephone Number	:	707-823-7616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	03/28/2013

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