Provider Demographics
NPI:1245220789
Name:MICHETTI, MICHAEL LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:MICHETTI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2606
Mailing Address - Country:US
Mailing Address - Phone:301-948-3668
Mailing Address - Fax:301-926-7787
Practice Address - Street 1:702 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2606
Practice Address - Country:US
Practice Address - Phone:301-948-3668
Practice Address - Fax:301-926-7787
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00270213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC601608100Medicaid
DC400209D98Medicare PIN
DC481007927Medicare PIN
DC601608100Medicaid