Provider Demographics
NPI:1902210586
Name:TIMENOVICH, MICHELINA LILLIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELINA
Middle Name:LILLIAN
Last Name:TIMENOVICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:MICHELINA
Other - Middle Name:TIMENOVICH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9367 RIBERENA CIR
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-6252
Mailing Address - Country:US
Mailing Address - Phone:818-430-3336
Mailing Address - Fax:
Practice Address - Street 1:2800 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1311
Practice Address - Country:US
Practice Address - Phone:805-238-7250
Practice Address - Fax:805-238-0165
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA167157Medicare PIN