Healthcare Provider Details

I. General information

NPI: 1104323286
Provider Name (Legal Business Name): EVAN MILLER MICHAELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GROOVER LOOP
ST AUGUSTINE FL
32086-6548
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 903-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 623-241-8716
  • Fax: 480-499-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0101580
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME181577
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberD0101580
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: