Provider Demographics
NPI:1518190503
Name:GILLESPIE, MICHELLE PATRICIA (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PATRICIA
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MIRACLE STRIP PKWY SW
Mailing Address - Street 2:UNIT 1203
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6650
Mailing Address - Country:US
Mailing Address - Phone:954-232-6754
Mailing Address - Fax:
Practice Address - Street 1:124 MIRACLE STRIP PKWY SW
Practice Address - Street 2:UNIT 1203
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-6650
Practice Address - Country:US
Practice Address - Phone:954-232-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine