Basic Information
| Provider Information | |||||||||
| NPI: | 1407202534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOOKRA | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393432052 | ||||||||
| FaxNumber: | 2393435348 | ||||||||
| Practice Location | |||||||||
| Address1: | 9981 S HEALTHPARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339083618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433396 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2016 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME145994 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME145994 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 106702000 | 05 | FL | MEDICAID |