Provider Demographics
NPI:1053369991
Name:PAGE, MICHELLE S (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:PAGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 WOODBINE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8782
Mailing Address - Country:US
Mailing Address - Phone:850-995-8600
Mailing Address - Fax:850-995-9060
Practice Address - Street 1:4288 WOODBINE RD
Practice Address - Street 2:SUITE D
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8795
Practice Address - Country:US
Practice Address - Phone:850-995-8600
Practice Address - Fax:850-995-9060
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35565OtherBLUE CROSS & BLUE SHIELD
FL259249500Medicaid
AL591-84273OtherBLUE CROSS & BLUE SHIELD
AL591-84273OtherBLUE CROSS & BLUE SHIELD
FL35565OtherBLUE CROSS & BLUE SHIELD