Provider Demographics
NPI:1407854839
Name:SELSOR, MICHELE L (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:L
Last Name:SELSOR
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 70TH WAY N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1305
Mailing Address - Country:US
Mailing Address - Phone:727-321-9488
Mailing Address - Fax:727-321-2033
Practice Address - Street 1:4104 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6304
Practice Address - Country:US
Practice Address - Phone:727-321-9488
Practice Address - Fax:727-321-2033
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-10
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2916213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340214201Medicaid
FL480034898OtherRR MEDICARE
FL340214200Medicaid
4687950002OtherDMEPOS
FL340214201Medicaid
FL340214200Medicaid