Healthcare Provider Details

I. General information

NPI: 1578551123
Provider Name (Legal Business Name): MICHAEL RYAN OBREGON O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2726 PONCE DE LEON BLVD
CORAL GABLES FL
33134-6005
US

IV. Provider business mailing address

441 NE 101ST ST
MIAMI SHORES FL
33138-2448
US

V. Phone/Fax

Practice location:
  • Phone: 305-444-9600
  • Fax:
Mailing address:
  • Phone: 305-527-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 2089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: