Provider Demographics
NPI:1689775710
Name:MICLEY, BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:MICLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1833
Mailing Address - Country:US
Mailing Address - Phone:508-583-2011
Mailing Address - Fax:508-586-5382
Practice Address - Street 1:495 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1833
Practice Address - Country:US
Practice Address - Phone:508-583-2011
Practice Address - Fax:508-586-5382
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW15693OtherBLUE CROSS
MA150703OtherHARVARD PILGRIM
MA0353574Medicaid
MA150703OtherHARVARD PILGRIM
MA403958Medicare ID - Type Unspecified