Provider Demographics
NPI:1386687333
Name:MAIN, MICHAEL DESMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DESMOND
Last Name:MAIN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:517-223-6780
Practice Address - Street 1:1220 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5488
Practice Address - Country:US
Practice Address - Phone:715-421-2111
Practice Address - Fax:715-421-2123
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-05-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI3021-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist