Provider Demographics
NPI:1154350577
Name:POWELL, MICHELLE R (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:3661 S. MIAMI AVE
Practice Address - Street 2:SUITE 806
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4214
Practice Address - Country:US
Practice Address - Phone:305-856-2171
Practice Address - Fax:305-859-7313
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-07-22
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Provider Licenses
StateLicense IDTaxonomies
FLME0078843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257959600Medicaid
FLG85460Medicare UPIN
FLE2955WMedicare PIN