Provider Demographics
NPI:1487725701
Name:MICKLAVZINA, CONNIE D (MD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:D
Last Name:MICKLAVZINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 RINGLING BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6102
Mailing Address - Country:US
Mailing Address - Phone:941-861-2900
Mailing Address - Fax:941-861-2828
Practice Address - Street 1:2200 RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-6102
Practice Address - Country:US
Practice Address - Phone:941-861-2900
Practice Address - Fax:941-861-2828
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47350207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046022200Medicaid
FL04300ZMedicare PIN