Provider Demographics
NPI:1710987151
Name:DORIAN, MICHELE M (OD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:DORIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 JENNERS VILLAGE CTR
Mailing Address - Street 2:
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-8102
Mailing Address - Country:US
Mailing Address - Phone:610-869-4200
Mailing Address - Fax:610-869-2511
Practice Address - Street 1:57 JENNERS VILLAGE CTR
Practice Address - Street 2:
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-8102
Practice Address - Country:US
Practice Address - Phone:610-869-4200
Practice Address - Fax:610-869-2511
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001453664Medicaid
PA0014536640003Medicaid
PA626390H6SMedicare PIN
PA001453664Medicaid
PA001453664Medicaid