Provider Demographics
NPI:1750354775
Name:LABOTZ, MICHELE (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:LABOTZ
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 1:100 GANNETT DRIVE, STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:50 FODEN RD, STE 3
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-523-8500
Practice Address - Fax:207-523-8591
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15152208000000X
HIMD117222080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA232478OtherHUSA
HI50525801Medicaid
HIA232478OtherHUSA
HI55344Medicare ID - Type Unspecified
HI50525801Medicaid