Provider Demographics
NPI:1396734851
Name:SCANNON, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:SCANNON
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 1:4200 N ARMENIA AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6438
Mailing Address - Country:US
Mailing Address - Phone:813-877-4811
Mailing Address - Fax:813-872-8978
Practice Address - Street 1:4200 N ARMENIA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6438
Practice Address - Country:US
Practice Address - Phone:813-877-4811
Practice Address - Fax:813-872-8978
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29315207N00000X
FLME00029315207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372329100Medicaid
FL51103ZMedicare PIN
FL372329100Medicaid