Provider Demographics
NPI:1912128232
Name:STICK, MICHAEL O (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:O
Last Name:STICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2599 SW COUNTY ROAD 360A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-8416
Mailing Address - Country:US
Mailing Address - Phone:850-973-3613
Mailing Address - Fax:
Practice Address - Street 1:256 SW WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1982
Practice Address - Country:US
Practice Address - Phone:850-973-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38518208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18556OtherBCBS OF FLORIDA
FL18556OtherBCBS OF FLORIDA
FL18556ZMedicare ID - Type UnspecifiedMEDICARE SINGLE NUMBER