Provider Demographics
NPI:1548508039
Name:MICHAEL G. MADISON OD PA
Entity type:Organization
Organization Name:MICHAEL G. MADISON OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-394-3068
Mailing Address - Street 1:914 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2751
Mailing Address - Country:US
Mailing Address - Phone:239-394-3068
Mailing Address - Fax:239-394-1078
Practice Address - Street 1:914 PARK AVE
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-2751
Practice Address - Country:US
Practice Address - Phone:239-394-3068
Practice Address - Fax:239-394-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty