Provider Demographics
NPI:1730432345
Name:MICHAEL G. DEGNAN, LLC
Entity type:Organization
Organization Name:MICHAEL G. DEGNAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEGNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-419-1235
Mailing Address - Street 1:181 WEBB DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3964
Mailing Address - Country:US
Mailing Address - Phone:863-419-1235
Mailing Address - Fax:863-419-9525
Practice Address - Street 1:181 WEBB DR
Practice Address - Street 2:SUITE A
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3944
Practice Address - Country:US
Practice Address - Phone:863-419-1235
Practice Address - Fax:863-419-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04657AMedicare UPIN