Provider Demographics
NPI:1508558438
Name:ERNST, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ERNST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 SOUTHLAND LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2283
Mailing Address - Country:US
Mailing Address - Phone:904-536-3187
Mailing Address - Fax:
Practice Address - Street 1:6830 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-1902
Practice Address - Country:US
Practice Address - Phone:904-786-2234
Practice Address - Fax:904-786-2242
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6456156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician