Provider Demographics
NPI:1538135090
Name:DIMAYUGA, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:DIMAYUGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:800 STERTHAUS DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-492-2956
Mailing Address - Fax:386-492-2984
Practice Address - Street 1:800 STERTHAUS DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-492-2956
Practice Address - Fax:386-492-2984
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0066666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE465528Medicare UPIN
FL255004Medicare ID - Type Unspecified