Provider Demographics
NPI:1396867743
Name:VIDIKAN, MICHELLE YOUNG (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:YOUNG
Last Name:VIDIKAN
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 1:1365 LAMPLIGHTER LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-8521
Mailing Address - Country:US
Mailing Address - Phone:937-767-7168
Mailing Address - Fax:
Practice Address - Street 1:2700 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3738
Practice Address - Country:US
Practice Address - Phone:937-439-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist