Provider Demographics
NPI:1285193193
Name:FOSS, MICHAEL GREGORY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:FOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 BEE RIDGE RD # 309
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2514
Mailing Address - Country:US
Mailing Address - Phone:941-926-6553
Mailing Address - Fax:941-296-8501
Practice Address - Street 1:2101 61ST ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5528
Practice Address - Country:US
Practice Address - Phone:941-677-9070
Practice Address - Fax:941-296-8501
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17790207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology