Provider Demographics
NPI:1316910565
Name:COGDILL, MICHAEL (ARNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COGDILL
Suffix:
Gender:M
Credentials:ARNP
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 1838
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-1838
Mailing Address - Country:US
Mailing Address - Phone:863-687-0931
Mailing Address - Fax:863-687-4021
Practice Address - Street 1:1750 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3103
Practice Address - Country:US
Practice Address - Phone:863-533-2030
Practice Address - Fax:863-519-9096
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1397132363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP04450001Medicare UPIN
FLE3956ZMedicare ID - Type Unspecified