Provider Demographics
NPI:1326020736
Name:FORD, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:FORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6651
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6651
Mailing Address - Country:US
Mailing Address - Phone:903-630-5037
Mailing Address - Fax:903-258-9643
Practice Address - Street 1:714 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-630-5037
Practice Address - Fax:903-258-9643
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7910207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328499401Medicaid
TX8EA343OtherBLUE CROSS BLUE SHIELD
TX324993YWSUMedicare PIN
TX328499401Medicaid
TX8EA343OtherBLUE CROSS BLUE SHIELD