Healthcare Provider Details

I. General information

NPI: 1073628392
Provider Name (Legal Business Name): MICHAEL ALAN KIMMELMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2279 S UNIVERSITY DR
DAVIE FL
33324-5828
US

IV. Provider business mailing address

16240 LA COSTA DR
WESTON FL
33326-1422
US

V. Phone/Fax

Practice location:
  • Phone: 954-473-0100
  • Fax: 954-474-7832
Mailing address:
  • Phone: 954-389-0559
  • Fax: 954-474-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: