Provider Demographics
NPI:1225069826
Name:BENGTSON, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:BENGTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:ARTHUR
Other - Last Name:BENGTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3515 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4706
Practice Address - Country:US
Practice Address - Phone:813-974-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME588872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372997400Medicaid
FL23209OtherBLUE CROSS BLUE SHIELD
F64705Medicare UPIN
FL23209OtherBLUE CROSS BLUE SHIELD