Provider Demographics
NPI:1316904022
Name:PENTALERI, MICHAEL D (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:PENTALERI
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:392-748-2002
Mailing Address - Fax:
Practice Address - Street 1:3402 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6214
Practice Address - Country:US
Practice Address - Phone:813-875-3950
Practice Address - Fax:813-872-2741
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78641174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00301196OtherMEDICARE RAILROAD
FL35376OtherBCBS
FLP01130437OtherRR MEDICARE
FL259013100Medicaid
GA003156073AOtherGA MEDICAID
FL301630OtherAVMED
FL35376OtherBCBS
FLP01130437OtherRR MEDICARE
FLH22960Medicare UPIN
FL35376TMedicare PIN
FL35376UMedicare PIN
FL35376VMedicare PIN
FL35376IMedicare PIN
FL35376CMedicare PIN
FL35376BMedicare PIN
FL35376HMedicare PIN
FL301630OtherAVMED
FL35376GMedicare PIN
FL35376AMedicare UPIN
FL35376YMedicare PIN
FL35376OMedicare PIN
GA003156073AOtherGA MEDICAID
FL35376PMedicare PIN
FL35376FMedicare PIN