Provider Demographics
NPI:1649316126
Name:HOFFMAN, MICCAH ALLYSON (OD)
Entity type:Individual
Prefix:DR
First Name:MICCAH
Middle Name:ALLYSON
Last Name:HOFFMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 E LUKES CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-9485
Mailing Address - Country:US
Mailing Address - Phone:812-219-7039
Mailing Address - Fax:
Practice Address - Street 1:4684 S US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5404
Practice Address - Country:US
Practice Address - Phone:812-232-4925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU96737Medicare UPIN
IN209470Medicare ID - Type Unspecified