Provider Demographics
NPI:1639103799
Name:GRIFFIN, MICHAEL A (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GRIFFIN
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 1:206 MEDICAL CARE WAY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:133-479-4879
Mailing Address - Fax:334-479-0658
Practice Address - Street 1:206 MEDICAL CARE WAY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-794-8797
Practice Address - Fax:334-479-0658
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS774-TA-431152W00000X
ALS774TA431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL127692Medicaid
AL127693Medicaid
1497052591OtherGROUP NPI
AL127692Medicaid