MEDICARE: MIKEL CALDERON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA9109411	FL
2	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BO758W	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1154567063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKEL CALDERON PA

Provider Business Mailing Address
First Line	:	2307 W BROWARD BLVD
Second Line	:	STE 200
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1417
Country	:	US
Telephone Number	:	954-792-1010
Fax Number	:	954-792-1199

Provider Business Practice Location Address
First Line	:	2307 W BROWARD BLVD
Second Line	:	STE 200
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1417
Country	:	US
Telephone Number	:	954-792-1010
Fax Number	:	954-792-1199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2008
Last Update Date	:	03/17/2018

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Directions to “ MIKEL CALDERON PA” Practice Location

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