1134221674 NPI number — DR. MICHELLE FALK O.D.

Table of content: DR. MICHELLE FALK O.D. (NPI 1134221674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134221674 NPI number — DR. MICHELLE FALK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FALK
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FANG
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134221674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1593 HEADWATERS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55129-6233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-337-0374
Provider Business Mailing Address Fax Number:
651-337-0374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9925 HUDSON PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-702-1231
Provider Business Practice Location Address Fax Number:
651-702-1239
Provider Enumeration Date:
09/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2857 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22 02293 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 36021 . This is a "AVESIS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 568960100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 308T4SA . This is a "BCBS MN CORP PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 308T5FA . This is a "BCBS MN INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 189811043835 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 241185 . This is a "NVA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 735559900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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