Provider Demographics
NPI:1639137524
Name:PRO, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:PRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 PRESIDENTIAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1108
Mailing Address - Country:US
Mailing Address - Phone:484-434-2700
Mailing Address - Fax:610-660-0419
Practice Address - Street 1:100 PRESIDENTIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1108
Practice Address - Country:US
Practice Address - Phone:484-434-2700
Practice Address - Fax:610-660-0419
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008603207W00000X
NJ25MA08060600207W00000X, 207WX0009X
PAMD428512207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0106356Medicaid
PA101630270-0001Medicaid
PA101630270-0002Medicaid
NJ0106356Medicaid
NJP00341678Medicare PIN
PA101630270-0002Medicaid
PA101630270-0001Medicaid
DE136388ZBJUMedicare PIN
PA102962FVUMedicare PIN