Provider Demographics
NPI:1285166157
Name:SHODEINDE, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SHODEINDE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-639-2015
Practice Address - Street 1:2001 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5148
Practice Address - Country:US
Practice Address - Phone:904-639-2112
Practice Address - Fax:904-639-2015
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142887207RI0200X, 208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty