Provider Demographics
NPI:1477548063
Name:SPELLICY, MICHAEL P (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:SPELLICY
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 1:1950 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:571-223-6780
Practice Address - Street 1:1404 FORREST AVE STE 1
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3478
Practice Address - Country:US
Practice Address - Phone:302-346-2020
Practice Address - Fax:302-346-4946
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0011433152W00000X
NY3797-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00600977Medicaid
NY38472BMedicare ID - Type Unspecified
NY16-1146750Medicare UPIN
NY0150360001Medicare NSC