Healthcare Provider Details

I. General information

NPI: 1700847217
Provider Name (Legal Business Name): MICHAEL BAHLATZIS D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W SAGAMORE AVE
CLEWISTON FL
33440-3514
US

IV. Provider business mailing address

9723 BLUE STONE CIR
FORT MYERS FL
33913-6722
US

V. Phone/Fax

Practice location:
  • Phone: 863-902-3032
  • Fax:
Mailing address:
  • Phone: 607-215-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number004310
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9115963
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4569
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: