Provider Demographics
NPI:1104181460
Name:MICHEL, KIMBERLY (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MICHEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 HACIENDA DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-4546
Mailing Address - Country:US
Mailing Address - Phone:760-631-0654
Mailing Address - Fax:760-631-0621
Practice Address - Street 1:1755 HACIENDA DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-4546
Practice Address - Country:US
Practice Address - Phone:760-631-0654
Practice Address - Fax:760-631-0621
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGH553ZMedicare PIN