Provider Demographics
NPI:1639152069
Name:LAST, MICHAEL ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:LAST
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 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-320-3303
Mailing Address - Fax:954-755-2224
Practice Address - Street 1:5430 W SAMPLE RD.
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33073-3453
Practice Address - Country:US
Practice Address - Phone:954-320-3303
Practice Address - Fax:954-755-2224
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55837387Medicaid
CO74305263OtherMEDICAID GROUP NUMBER
CO55837387Medicaid
COC810776OtherMEDICARE GROUP NUMBER
COP00624700Medicare PIN
CO811289Medicare PIN
COC810123Medicare PIN
CO348308OtherMEDICARE GROUP NUMBER
COC810776OtherMEDICARE GROUP NUMBER
CO55837387Medicaid