Basic Information
| Provider Information | |||||||||
| NPI: | 1083677066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODARD | ||||||||
| FirstName: | MICHEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1475 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052437249 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1475 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052437249 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME50681 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0488461-00 | 05 | FL | MEDICAID |