Provider Demographics
NPI:1689696833
Name:CASELNOVA, MICHAEL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:CASELNOVA
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 1:12470 TELECOM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-779-6303
Mailing Address - Fax:888-977-1998
Practice Address - Street 1:12470 TELECOM DR STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-779-6303
Practice Address - Fax:888-977-1998
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11631207Q00000X
FLME45762208M00000X
FLME 45762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080008869OtherRAILROAD WORKERS MEDICARE
FL045380300Medicaid
FL045380300Medicaid
MT011002335Medicare PIN
FL51270Medicare ID - Type UnspecifiedPROVIDER NUMBER