Provider Demographics
NPI:1770559544
Name:TOMA, MICHELLE DENISE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:TOMA
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 1:11513 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5001
Mailing Address - Country:US
Mailing Address - Phone:407-249-1234
Mailing Address - Fax:407-249-1755
Practice Address - Street 1:10105 CLEAR VISTA ST STE B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6376
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:407-249-1755
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091420208000000X
FLME145388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108903900Medicaid
IL36091420Medicaid