Provider Demographics
NPI:1619988748
Name:DR. MICHELLE R. TRUMP PC
Entity Type:Organization
Organization Name:DR. MICHELLE R. TRUMP PC
Other - Org Name:DR. MICHELLE R. TRUMP, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:TRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:603-630-3686
Mailing Address - Street 1:750 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-2908
Mailing Address - Country:US
Mailing Address - Phone:603-630-3686
Mailing Address - Fax:570-329-0190
Practice Address - Street 1:750 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2908
Practice Address - Country:US
Practice Address - Phone:603-630-3686
Practice Address - Fax:570-329-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOB009154152W00000X
VA0618000608152W00000X
PAOEG001436152W00000X
NH789152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU72748Medicare UPIN