Provider Demographics
NPI:1114781218
Name:KORNEEV, MICHAL
Entity Type:Individual
Prefix:
First Name:MICHAL
Middle Name:
Last Name:KORNEEV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 GRIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5519
Mailing Address - Country:US
Mailing Address - Phone:754-280-1144
Mailing Address - Fax:
Practice Address - Street 1:3346 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-5519
Practice Address - Country:US
Practice Address - Phone:754-280-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7947156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter