Provider Demographics
NPI:1457326472
Name:HARGREAVES, MICHELE ST MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ST MARTIN
Last Name:HARGREAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:BAUCHET
Other - Last Name:ST MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:4203 BELFORT RD
Practice Address - Street 2:STE 340
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1409
Practice Address - Country:US
Practice Address - Phone:904-880-0911
Practice Address - Fax:904-880-9388
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425320174400000X
FLME98473207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278642700Medicaid
FL278642700Medicaid
FLAF833YMedicare PIN
PA091919EN4OtherMEDICARE ID - TYPE UNSPECIFIED