Provider Demographics
NPI:1376856831
Name:DESAUTELS, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DESAUTELS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 FOREST DR
Mailing Address - Street 2:STE. 118
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-5000
Mailing Address - Country:US
Mailing Address - Phone:803-678-4662
Mailing Address - Fax:803-678-4667
Practice Address - Street 1:5580 FOREST DR
Practice Address - Street 2:STE. 118
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-5000
Practice Address - Country:US
Practice Address - Phone:803-678-4662
Practice Address - Fax:803-678-4667
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist