Provider Demographics
NPI:1376645226
Name:EBRAHIM, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:EBRAHIM
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 1:1880 HARTFORD HWY APT E23
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-4938
Mailing Address - Country:US
Mailing Address - Phone:334-712-4551
Mailing Address - Fax:
Practice Address - Street 1:3300 S OATES ST
Practice Address - Street 2:PRECISION VISION, PC
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5694
Practice Address - Country:US
Practice Address - Phone:334-702-0508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-129 TA-427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51096728OtherBLUE CROSS BLUE SHIELD