Provider Demographics
NPI:1699977694
Name:MUSTO, MICHELE L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:L
Last Name:MUSTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHELE
Other - Middle Name:M
Other - Last Name:WELLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-202-3860
Practice Address - Fax:904-202-3846
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000556207Q00000X
SCTL31424207QA0505X
FL112784207QA0505X
NC180956207QA0505X
FLME112784208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013879800Medicaid
GA770574093AMedicaid
GA01067717OtherAMERIGROUP MEDICAID
GA395491OtherWELLCARE MEDICAID
FL013879800Medicaid
GAP00406198Medicare PIN
FLHZ917ZMedicare PIN
FLHZ917ZMedicare PIN