Provider Demographics
NPI:1932764883
Name:MICHAELIS, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1909
Mailing Address - Country:US
Mailing Address - Phone:218-727-1004
Mailing Address - Fax:
Practice Address - Street 1:213 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1909
Practice Address - Country:US
Practice Address - Phone:218-727-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program