Provider Demographics
NPI:1205966926
Name:ISICOFF, MICHAEL ALAN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:ISICOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:416 OCEAN GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-8721
Mailing Address - Country:US
Mailing Address - Phone:904-461-1723
Mailing Address - Fax:
Practice Address - Street 1:6 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3808
Practice Address - Country:US
Practice Address - Phone:386-447-6615
Practice Address - Fax:386-447-1266
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLMEOO83733173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H64823Medicare UPIN