Provider Demographics
NPI:1356780670
Name:MICHAEL, JACOB ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANTHONY
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 PAVILION PKWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2884
Practice Address - Country:US
Practice Address - Phone:859-291-9464
Practice Address - Fax:859-291-3222
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6219152W00000X
KY2007DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist