Provider Demographics
NPI:1497265326
Name:MERRITT, MICHAEL CLIVE (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CLIVE
Last Name:MERRITT
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 1:20 CENTRAL AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 CENTRAL AVE FL 1
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1201
Practice Address - Country:US
Practice Address - Phone:540-834-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty