Provider Demographics
NPI:1205992138
Name:FELICIANO, MICHAEL NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NICHOLAS
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-0226
Mailing Address - Country:US
Mailing Address - Phone:972-526-0340
Mailing Address - Fax:972-996-1857
Practice Address - Street 1:7501 LAKEVIEW PKWY
Practice Address - Street 2:STE 160
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-9322
Practice Address - Country:US
Practice Address - Phone:972-526-0340
Practice Address - Fax:972-996-1857
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2901207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DF228OtherBLUE CRISS BLUE SHIELD
TXP01076174OtherRAILROAD MEDICARE
TX089970007Medicaid
TX8DF229OtherBLUE CROSS BLUE SHIELD
TX089970006Medicaid
TXP01076168OtherRAILROAD MEDICARE
TXP01076174OtherRAILROAD MEDICARE
TX089970007Medicaid