Healthcare Provider Details

I. General information

NPI: 1205966926
Provider Name (Legal Business Name): MICHAEL ALAN ISICOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OFFICE PARK DR
PALM COAST FL
32137-3808
US

IV. Provider business mailing address

416 OCEAN GROVE CIR
ST AUGUSTINE FL
32080-8721
US

V. Phone/Fax

Practice location:
  • Phone: 386-447-6615
  • Fax: 386-447-1266
Mailing address:
  • Phone: 904-461-1723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMEOO83733
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: