Healthcare Provider Details

I. General information

NPI: 1073884375
Provider Name (Legal Business Name): MICHELLE ELIZABETH WILSON LATTING M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE ELIZABETH WILSON M.D.

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 17TH ST
MIAMI FL
33136-1119
US

IV. Provider business mailing address

1638 NW 10TH AVE BLDG SUITE114
MIAMI FL
33136-1015
US

V. Phone/Fax

Practice location:
  • Phone: 305-326-6111
  • Fax:
Mailing address:
  • Phone: 305-482-4775
  • Fax: 305-326-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number2016-01339
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number136723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: