Provider Demographics
NPI:1558587402
Name:EMERSON, MICHAEL A
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:EMERSON
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 1:8685 LA MESA BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3992
Mailing Address - Country:US
Mailing Address - Phone:619-466-6825
Mailing Address - Fax:619-462-9239
Practice Address - Street 1:8685 LA MESA BOULEVARD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3992
Practice Address - Country:US
Practice Address - Phone:619-466-6825
Practice Address - Fax:619-462-9239
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3851156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0496090001Medicare ID - Type Unspecified