Provider Demographics
NPI:1083046502
Name:COVILI, MICHELLE BRODASKY (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BRODASKY
Last Name:COVILI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:PAULINE
Other - Last Name:BRODASKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:477 MCLAWS CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-6316
Mailing Address - Country:US
Mailing Address - Phone:757-984-9650
Mailing Address - Fax:757-510-9232
Practice Address - Street 1:477 MCLAWS CIR STE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-6316
Practice Address - Country:US
Practice Address - Phone:757-984-9650
Practice Address - Fax:757-510-9232
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12513207Q00000X
VA0102206488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012038800Medicaid
FL14UW2OtherFLORIDA BLUE
FLHU804ZMedicare PIN