Provider Demographics
NPI:1427008168
Name:SALL, MICHELLE L (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:SALL
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 1:1340 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2617
Mailing Address - Country:US
Mailing Address - Phone:919-552-3181
Mailing Address - Fax:919-552-0197
Practice Address - Street 1:1340 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2617
Practice Address - Country:US
Practice Address - Phone:919-552-3181
Practice Address - Fax:919-552-0197
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093MJOtherBCBS
NC89093MJMedicaid
NC093MJOtherBCBS
NC89093MJMedicaid