Provider Demographics
NPI:1053375311
Name:AGUAYO, MICHELE A (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:AGUAYO
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 1:2594 LOGANVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1617
Mailing Address - Country:US
Mailing Address - Phone:678-225-4999
Mailing Address - Fax:678-225-5546
Practice Address - Street 1:2594 LOGANVILLE HWY
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1617
Practice Address - Country:US
Practice Address - Phone:678-225-4999
Practice Address - Fax:678-225-5546
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00344045OtherRR MEDICARE
GAP00344045OtherRR MEDICARE
GAE58849Medicare UPIN