Provider Demographics
NPI:1235240664
Name:DATTOLI, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:DATTOLI
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 1:2803 FRUITVILLE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-5344
Mailing Address - Country:US
Mailing Address - Phone:941-957-4926
Mailing Address - Fax:
Practice Address - Street 1:2803 FRUITVILLE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-5344
Practice Address - Country:US
Practice Address - Phone:941-957-4926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11366Medicare ID - Type Unspecified
FLE62996Medicare UPIN