Provider Demographics
NPI:1114560034
Name:SANSEVERINO, MICHELLE THERESA (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:THERESA
Last Name:SANSEVERINO
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 1:8565 BOCA GLADES BLVD W # CONDOG
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4087
Mailing Address - Country:US
Mailing Address - Phone:954-214-4261
Mailing Address - Fax:
Practice Address - Street 1:19575 BISCAYNE BLVD STE 579
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2312
Practice Address - Country:US
Practice Address - Phone:305-932-7373
Practice Address - Fax:305-933-8338
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5740152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist