Provider Demographics
NPI:1871676304
Name:BURKHARDT BULLION, MICHELLE LEE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:BURKHARDT BULLION
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 1:1179 WHITEHALL RD B
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2497
Mailing Address - Country:US
Mailing Address - Phone:231-744-3573
Mailing Address - Fax:231-719-9016
Practice Address - Street 1:1179 WHITEHALL RD B
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-2497
Practice Address - Country:US
Practice Address - Phone:231-744-3573
Practice Address - Fax:231-719-9016
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004094152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU86989Medicare UPIN
MION90760Medicare ID - Type Unspecified