Provider Demographics
NPI:1538121728
Name:SIMPSON, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SIMPSON
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 1:120 1ST AVE E
Mailing Address - Street 2:MR 10809
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1209
Mailing Address - Country:US
Mailing Address - Phone:763-689-1494
Mailing Address - Fax:763-691-8395
Practice Address - Street 1:120 1ST AVE E
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1209
Practice Address - Country:US
Practice Address - Phone:763-689-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN693718700Medicaid
U6449Medicare UPIN
410001166Medicare ID - Type Unspecified