Provider Demographics
NPI:1275739021
Name:TRAVER, MICHAEL FAHEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FAHEY
Last Name:TRAVER
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 1:718 DUFFER LN
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-9318
Mailing Address - Country:US
Mailing Address - Phone:808-721-6497
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DRIVE
Practice Address - Street 2:PTU
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD151802084P0800X
FLME1228402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015007900Medicaid