Provider Demographics
NPI:1134807506
Name:FORD, MICHAELLA MARIE (OD)
Entity type:Individual
Prefix:
First Name:MICHAELLA
Middle Name:MARIE
Last Name:FORD
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 1:4499 TOWN CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3425
Mailing Address - Country:US
Mailing Address - Phone:810-691-2450
Mailing Address - Fax:
Practice Address - Street 1:3241 S MICHIGAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-949-7119
Practice Address - Fax:312-949-7617
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011769152W00000X
MI4901005759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist