Provider Demographics
NPI:1619034790
Name:URSICH, MICHAEL VINCENT (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:URSICH
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 1:28633 S WESTERN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0827
Mailing Address - Country:US
Mailing Address - Phone:310-548-6363
Mailing Address - Fax:
Practice Address - Street 1:28633 S WESTERN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0827
Practice Address - Country:US
Practice Address - Phone:310-548-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7595T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP 7595Medicare ID - Type Unspecified