Basic Information
| Provider Information | |||||||||
| NPI: | 1770559544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOMA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11513 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Practice Location | |||||||||
| Address1: | 10105 CLEAR VISTA ST STE B | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328326376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036091420 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME145388 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 108903900 | 05 | FL | MEDICAID |