Provider Demographics
NPI:1164857587
Name:GONSALVES, MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2FLOOR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2675 WINKLER AVE FL 2FLOOR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9342
Practice Address - Country:US
Practice Address - Phone:855-979-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3068207R00000X
FLOS13272208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015038200Medicaid
FL1407SOtherBCBS FL
FLIE936ZMedicare PIN