Provider Demographics
NPI:1962447912
Name:DETRAGLIA, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DETRAGLIA
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 1:130 ALLENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3305
Mailing Address - Country:US
Mailing Address - Phone:585-410-6545
Mailing Address - Fax:585-410-6560
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:ROCHESTER GENERAL HOSPITAL
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-4159
Practice Address - Fax:585-922-3731
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169401-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010016940OtherEXCELLUS BLUE CHOICE
NYCAN169401-7OtherWORKERS' COMPENSATION
NY01041881Medicaid
NY103217AFOtherPREFERRED CARE
NY3417OtherEXCELLUS BC/BS
NYP010016940OtherEXCELLUS BLUE CHOICE
NY01041881Medicaid