Provider Demographics
NPI:1427021070
Name:SHOTWELL, MICHAEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:SHOTWELL
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 1:19105 N US HIGHWAY 41
Mailing Address - Street 2:STE 300
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4206
Mailing Address - Country:US
Mailing Address - Phone:770-704-6101
Mailing Address - Fax:
Practice Address - Street 1:684 SIXES RD
Practice Address - Street 2:SUITE 225
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30115-8721
Practice Address - Country:US
Practice Address - Phone:770-704-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053168208600000X
FLME127994208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA163054290AMedicaid
GAH85156Medicare UPIN
GA163054290AMedicaid