Provider Demographics
NPI:1629024435
Name:CHIDESTER, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:CHIDESTER
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 1:3375 BURNS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4349
Mailing Address - Country:US
Mailing Address - Phone:561-355-8388
Mailing Address - Fax:561-355-3848
Practice Address - Street 1:3375 BURNS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4349
Practice Address - Country:US
Practice Address - Phone:561-355-8388
Practice Address - Fax:561-355-3848
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048740600Medicaid
FL04947VMedicare PIN
FLD21003Medicare UPIN