Provider Demographics
NPI:1740420686
Name:HESSEN, MICHELLE MARJORIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARJORIE
Last Name:HESSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:MARJORIE
Other - Last Name:KUBANCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 64481
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4481
Mailing Address - Country:US
Mailing Address - Phone:410-955-5080
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-5080
Practice Address - Fax:410-614-1670
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2108152W00000X
PAOEG002283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419434900Medicaid
PAP00783551OtherRAILROAD MEDICARE
PA1024004990001Medicaid
PAP00783551OtherRAILROAD MEDICARE
MD419434900Medicaid