Provider Demographics
NPI:1578614475
Name:NELL, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:NELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:NELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1148 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-2208
Mailing Address - Country:US
Mailing Address - Phone:936-756-8612
Mailing Address - Fax:936-756-8603
Practice Address - Street 1:1148 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2208
Practice Address - Country:US
Practice Address - Phone:936-756-8612
Practice Address - Fax:936-756-8603
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2624T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT90847Medicare UPIN
TXT90847Medicare UPIN