Provider Demographics
NPI:1134221674
Name:FALK, MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:FALK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:FANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1593 HEADWATERS LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6233
Mailing Address - Country:US
Mailing Address - Phone:651-337-0374
Mailing Address - Fax:651-337-0374
Practice Address - Street 1:9925 HUDSON PL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-702-1231
Practice Address - Fax:651-702-1239
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22 02293OtherMEDICA
MN36021OtherAVESIS
MN568960100Medicaid
MN308T4SAOtherBCBS MN CORP PROVIDER #
MN308T5FAOtherBCBS MN INDIVIDUAL
MN189811043835OtherPREFERRED ONE
MN241185OtherNVA
MN735559900Medicaid
MN189811043835OtherPREFERRED ONE
MNV05854Medicare UPIN