Provider Demographics
NPI:1265873475
Name:DERHEIMER, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DERHEIMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:FONDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:12990 MANCHESTER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:314-909-0633
Mailing Address - Fax:314-909-0391
Practice Address - Street 1:12990 MANCHESTER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1860
Practice Address - Country:US
Practice Address - Phone:314-909-0633
Practice Address - Fax:314-909-0391
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013025320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013025320OtherOPTOMETRIC LICENSE