Provider Demographics
NPI:1801885116
Name:ALLEN, MICHAEL ROSS (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROSS
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2407
Mailing Address - Country:US
Mailing Address - Phone:850-477-9015
Mailing Address - Fax:850-478-5227
Practice Address - Street 1:4850 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2407
Practice Address - Country:US
Practice Address - Phone:850-477-9015
Practice Address - Fax:850-478-5227
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0775T213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1449868Medicaid
IA54775OtherWELLMARK
IAV01859Medicare UPIN
IAI6399Medicare PIN