Provider Demographics
NPI:1891007688
Name:BLEW, MICHELLE LAUREN ZICKEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LAUREN ZICKEL
Last Name:BLEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LAUREN
Other - Last Name:ZICKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:605 LINCOLN ST
Mailing Address - Street 2:VA CWMHS - WORCESTER OUTPATIENT CLINIC
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1901
Mailing Address - Country:US
Mailing Address - Phone:508-856-0104
Mailing Address - Fax:508-853-4961
Practice Address - Street 1:605 LINCOLN ST
Practice Address - Street 2:VA CWMHS - WORCESTER OUTPATIENT CLINIC
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1901
Practice Address - Country:US
Practice Address - Phone:508-856-0104
Practice Address - Fax:508-853-4961
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002586152W00000X
IL046010377152W00000X
MA4902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist