Provider Demographics
NPI:1639126931
Name:BLAIR, MICHELE M (DO)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:BLAIR
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 1:11970 PRINCE CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-7507
Mailing Address - Country:US
Mailing Address - Phone:239-462-8948
Mailing Address - Fax:
Practice Address - Street 1:11970 PRINCE CHARLES CT
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-7507
Practice Address - Country:US
Practice Address - Phone:239-462-8948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS90692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS9069OtherFLORIDA LICENSE
16149OtherBCBS
FL273116900Medicaid
FL273116900Medicaid
FLOS9069OtherFLORIDA LICENSE
FL16149XMedicare PIN