Provider Demographics
NPI:1659776706
Name:MICHAEL J. NIEDERKORN, O.D., P.A.
Entity Type:Organization
Organization Name:MICHAEL J. NIEDERKORN, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NIEDERKORN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-423-4435
Mailing Address - Street 1:810 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 104B
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-6782
Mailing Address - Country:US
Mailing Address - Phone:972-423-4435
Mailing Address - Fax:
Practice Address - Street 1:810 N CENTRAL EXPY
Practice Address - Street 2:SUITE 104B
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6782
Practice Address - Country:US
Practice Address - Phone:972-423-4435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5266TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty