Provider Demographics
NPI:1275591026
Name:MICHELSEN, THOMAS A (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:MICHELSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8928
Mailing Address - Country:US
Mailing Address - Phone:904-725-0200
Mailing Address - Fax:904-721-5711
Practice Address - Street 1:1731 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8928
Practice Address - Country:US
Practice Address - Phone:904-725-0200
Practice Address - Fax:904-721-5711
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 3395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274560700Medicaid
FL274560700Medicaid
FLP00346616Medicare PIN
FL81968YMedicare PIN