Provider Demographics
NPI:1336497841
Name:AUTRY, MICHAEL DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:AUTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7927 SW 13TH RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3320
Mailing Address - Country:US
Mailing Address - Phone:352-328-9830
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-271-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT82679247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist