Healthcare Provider Details

I. General information

NPI: 1003201096
Provider Name (Legal Business Name): MICHAEL MARTIN WACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-2916
  • Fax:
Mailing address:
  • Phone: 813-745-7365
  • Fax: 813-449-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME168096
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: