Provider Demographics
NPI:1548213879
Name:CAVALLARO, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:CAVALLARO
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:PO BOX 1678
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32302-1678
Mailing Address - Country:US
Mailing Address - Phone:850-878-4102
Mailing Address - Fax:850-942-4155
Practice Address - Street 1:1600 PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5304
Practice Address - Country:US
Practice Address - Phone:850-878-4127
Practice Address - Fax:850-878-0337
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME542632085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255299000Medicaid
GA000841057AMedicaid
GA000841057DMedicaid
GA000841057CMedicaid
FLE1603OtherBCBS
FLE1603OtherBCBS
G83507Medicare UPIN
GA000841057DMedicaid
300093247Medicare PIN
FL255299000Medicaid
FLE1603YMedicare PIN