Provider Demographics
NPI:1821044553
Name:MICHAELS, GREGORY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:MICHAELS
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 1:13131 CORBEL CIR
Mailing Address - Street 2:#312
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-6833
Mailing Address - Country:US
Mailing Address - Phone:239-267-2030
Mailing Address - Fax:
Practice Address - Street 1:63 BARKLEY CIR
Practice Address - Street 2:STE. 100 & 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4514
Practice Address - Country:US
Practice Address - Phone:239-938-3500
Practice Address - Fax:239-278-0055
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME829422085R0202X
CAG619222085R0202X, 2085R0204X
FLME 829422085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264701000Medicaid
5773317OtherCIGNA
FLP00318896OtherRR MEDICARE FRL
226258OtherAMERIGROUP
ME82942OtherFL WC CERTIFICATION
O6452OtherBCBSFL
FL300130144Medicare PIN
5773317OtherCIGNA
FLP00318896OtherRR MEDICARE FRL
O6452OtherBCBSFL
FL300127824Medicare ID - Type UnspecifiedRR FL RAD CONSULTANTS
F12243Medicare UPIN