Provider Demographics
NPI:1578857207
Name:HOMERICK, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:HOMERICK
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 1:4230 STONEY POINT RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1476
Mailing Address - Country:US
Mailing Address - Phone:516-330-8889
Mailing Address - Fax:
Practice Address - Street 1:4230 STONEY POINT RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1476
Practice Address - Country:US
Practice Address - Phone:516-330-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-28
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME119113207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program