Healthcare Provider Details

I. General information

NPI: 1881213650
Provider Name (Legal Business Name): MARY MICHAEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NW 13TH ST STE 100
BOCA RATON FL
33486-2269
US

IV. Provider business mailing address

1906 MUIRFIELD WAY
OLDSMAR FL
34677-1935
US

V. Phone/Fax

Practice location:
  • Phone: 305-740-6140
  • Fax:
Mailing address:
  • Phone: 727-389-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS18944
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS18944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: