Provider Demographics
NPI:1013980267
Name:ANGLIN, MICKEL WRAY (M D)
Entity Type:Individual
Prefix:
First Name:MICKEL
Middle Name:WRAY
Last Name:ANGLIN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13045 SUMMERFIELD SQUARE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578
Mailing Address - Country:US
Mailing Address - Phone:813-672-1385
Mailing Address - Fax:813-672-8904
Practice Address - Street 1:13045 SUMMERFIELD SQUARE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7402
Practice Address - Country:US
Practice Address - Phone:813-672-1385
Practice Address - Fax:813-672-8904
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278352500Medicaid
FLU4295AMedicare ID - Type Unspecified
FLAH062Medicare UPIN
FLI26305Medicare UPIN