Provider Demographics
NPI:1396705570
Name:MICELI, GERALD (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:MICELI
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 1:300 CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5909
Mailing Address - Country:US
Mailing Address - Phone:386-317-8620
Mailing Address - Fax:386-317-8625
Practice Address - Street 1:300 CLYDE MORRIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5909
Practice Address - Country:US
Practice Address - Phone:386-317-8620
Practice Address - Fax:386-317-8625
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62517207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25294WOtherMEDICARE ID
FLME62517OtherVHN
FL25294OtherBCBS
FL460003874OtherRAILROAD MEDICARE
FLME62517OtherUHC
FLME62517OtherUNITED BENEFITS
FL25294WOtherMEDICARE ID
FL375335200Medicaid