Provider Demographics
NPI:1912990425
Name:PEDERSEN, MICHELLE H (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:H
Last Name:PEDERSEN
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 1:1950 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:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:120 MARTIN DRIVE
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-2408
Practice Address - Country:US
Practice Address - Phone:262-692-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38609500Medicaid
WI7419074OtherAETNA
U70301Medicare UPIN