Provider Demographics
NPI:1093774150
Name:MAKEDONSKY, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MAKEDONSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6918 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1621
Mailing Address - Country:US
Mailing Address - Phone:415-750-0100
Mailing Address - Fax:
Practice Address - Street 1:6918 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1621
Practice Address - Country:US
Practice Address - Phone:415-750-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12463T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124630Medicaid
CA99899Medicare UPIN
CASD0124630Medicare PIN
CASD0124630Medicaid