Provider Demographics
NPI:1760739809
Name:DE LEON, MICHELLE NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:DE LEON
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 1:10101 W FLAGLER ST
Mailing Address - Street 2:TARGET OPTICAL
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1808
Mailing Address - Country:US
Mailing Address - Phone:305-424-8451
Mailing Address - Fax:
Practice Address - Street 1:10101 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1808
Practice Address - Country:US
Practice Address - Phone:305-424-8451
Practice Address - Fax:305-424-8526
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4703152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist