Provider Demographics
NPI:1164503587
Name:DIAB, MICHEL BOLUS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHEL
Middle Name:BOLUS
Last Name:DIAB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-7020
Mailing Address - Fax:352-265-0721
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-7020
Practice Address - Fax:352-265-0721
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLTRN 7917207Q00000X
FLME106892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDF104ZMedicare PIN