Basic Information
| Provider Information | |||||||||
| NPI: | 1962401463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZELK | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 PETALUMA AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954724281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237616 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 652 PETALUMA AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954724256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237616 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | E-1505 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | E-1505 | AR | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | C54385 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | C54385 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 140545001 | 05 | AR | MEDICAID |