Provider Demographics
NPI:1356437545
Name:MONTICELLO, MICHELLE LAFORET (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAFORET
Last Name:MONTICELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2761
Mailing Address - Country:US
Mailing Address - Phone:989-631-5721
Mailing Address - Fax:989-631-5721
Practice Address - Street 1:419 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2761
Practice Address - Country:US
Practice Address - Phone:989-631-5721
Practice Address - Fax:989-631-5721
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058009207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3151493Medicaid
MI3151493Medicaid
OM11300004Medicare ID - Type Unspecified