Healthcare Provider Details

I. General information

NPI: 1902127061
Provider Name (Legal Business Name): MICHAEL ICELY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 W 24TH ST
YUMA AZ
85364-6136
US

IV. Provider business mailing address

2149 W 24TH ST
YUMA AZ
85364-6136
US

V. Phone/Fax

Practice location:
  • Phone: 928-726-1100
  • Fax: 928-341-0881
Mailing address:
  • Phone: 928-726-1100
  • Fax: 928-341-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1754
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: