Provider Demographics
NPI:1770703977
Name:MICHELLE R ROUNTREE O D P A
Entity type:Organization
Organization Name:MICHELLE R ROUNTREE O D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROUNTREE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-885-8488
Mailing Address - Street 1:10800 PINES BLVD
Mailing Address - Street 2:STE 7
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5216
Mailing Address - Country:US
Mailing Address - Phone:954-885-8488
Mailing Address - Fax:954-885-4919
Practice Address - Street 1:10800 PINES BLVD
Practice Address - Street 2:STE 7
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-885-8488
Practice Address - Fax:954-885-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF 740OtherMEDICARE PTAN
FLU97384Medicare UPIN