Provider Demographics
NPI:1700847217
Name:BAHLATZIS, MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BAHLATZIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9723 BLUE STONE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-6722
Mailing Address - Country:US
Mailing Address - Phone:607-215-3887
Mailing Address - Fax:
Practice Address - Street 1:524 W SAGAMORE AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3514
Practice Address - Country:US
Practice Address - Phone:863-902-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004310213ES0131X
FLPA9115963363AS0400X
FLPO4569213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039909Medicaid
NYR88957Medicare UPIN
NYDD2224Medicare ID - Type UnspecifiedUPSTATE