Provider Demographics
NPI:1487686051
Name:MICHALOS, PHILLIP JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOHN
Last Name:MICHALOS
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 1:16400 HILLIARD RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5610
Mailing Address - Country:US
Mailing Address - Phone:216-228-1800
Mailing Address - Fax:216-228-1162
Practice Address - Street 1:10680 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5411
Practice Address - Country:US
Practice Address - Phone:216-671-2998
Practice Address - Fax:216-671-6985
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324232Medicaid
OH0517952Medicare ID - Type Unspecified
OH0324232Medicaid