Provider Demographics
NPI:1831161660
Name:DESAUTEL, MICHAEL G (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:DESAUTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-205-8981
Mailing Address - Fax:352-391-6498
Practice Address - Street 1:609 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4638
Practice Address - Country:US
Practice Address - Phone:352-726-9707
Practice Address - Fax:352-726-8763
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME78107208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46851OtherBCBS FLORIDA
FL340016756OtherRAILROAD MEDICARE
FL340016756OtherRAILROAD MEDICARE
FL340016756OtherRAILROAD MEDICARE
FL256825000Medicaid
FLE2416ZMedicare PIN