Provider Demographics
NPI:1902267008
Name:IDIART, MICHAEL GENE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GENE
Last Name:IDIART
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 E LESTER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-1996
Mailing Address - Country:US
Mailing Address - Phone:559-655-5531
Mailing Address - Fax:
Practice Address - Street 1:23370 ROAD 22
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-8504
Practice Address - Country:US
Practice Address - Phone:559-655-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TF0200X
CAPSY29830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY29830OtherCALIFORNIA BOARD OF PSYCHOLOGY