Healthcare Provider Details

I. General information

NPI: 1699977694
Provider Name (Legal Business Name): MICHELE L. MUSTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE M. WELLINGTON M.D.

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR STE 304
JACKSONVILLE FL
32207-8205
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-3860
  • Fax: 904-202-3846
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000556
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberTL31424
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number112784
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number180956
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME112784
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: