Provider Demographics
NPI:1689937997
Name:DE LOTA, MICHAEL FORONDA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FORONDA
Last Name:DE LOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-406-6216
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT DR
Practice Address - Street 2:SUITE 400
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6146
Practice Address - Country:US
Practice Address - Phone:512-295-1333
Practice Address - Fax:512-406-7327
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10044611207Q00000X
TXQ3171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343719603Medicaid
TX343719604Medicaid
TX343719604Medicaid
TX343719603Medicaid
TX396315YKXYMedicare PIN