Provider Demographics
NPI:1679829758
Name:PACKLES, MICHELLE RENEE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:PACKLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CLOCK TOWER LN
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1003
Mailing Address - Country:US
Mailing Address - Phone:516-626-1340
Mailing Address - Fax:
Practice Address - Street 1:37 CLOCK TOWER LN
Practice Address - Street 2:
Practice Address - City:OLD WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11568-1003
Practice Address - Country:US
Practice Address - Phone:516-626-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225522207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology