Provider Demographics
NPI:1467946905
Name:CHAMOUN, MICHELLE MARY (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARY
Last Name:CHAMOUN
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 1:1400 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2134
Mailing Address - Country:US
Mailing Address - Phone:321-841-1869
Mailing Address - Fax:407-849-6994
Practice Address - Street 1:1400 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:321-841-1869
Practice Address - Fax:407-849-6994
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1675492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122388500Medicaid