Provider Demographics
NPI:1396767208
Name:HERNANDEZ, MICHELLE M (OD)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:M
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:BOYCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2560 GULF TO BAY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-4421
Mailing Address - Country:US
Mailing Address - Phone:727-799-3772
Mailing Address - Fax:727-791-6598
Practice Address - Street 1:2560 GULF TO BAY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-4421
Practice Address - Country:US
Practice Address - Phone:727-799-3772
Practice Address - Fax:727-791-6598
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078935600Medicaid
20408Medicare ID - Type Unspecified
FL078935600Medicaid