Provider Demographics
NPI:1578676805
Name:MADISON, MICHAEL GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLENN
Last Name:MADISON
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 1:914 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2751
Mailing Address - Country:US
Mailing Address - Phone:239-394-3068
Mailing Address - Fax:
Practice Address - Street 1:914 PARK AVE
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-2751
Practice Address - Country:US
Practice Address - Phone:239-394-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20832Medicare ID - Type Unspecified
69908Medicare UPIN