Provider Demographics
NPI:1659305191
Name:TANKOVICH, MICHAEL CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:TANKOVICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:25 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1615
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:3540-C NORTH 126TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2403
Practice Address - Country:US
Practice Address - Phone:262-790-9559
Practice Address - Fax:262-790-9609
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist